Fema Form 086-0-20 - Adjuster Preliminary Damage Assessment (Page 3 of 4) in pdf

DEPARTMENT OF HOMELAND SECURITY

OMB 1660-0005

Federal Emergency Management Agency

EXPIRES April 30, 2017

ADJUSTER PRELIMINARY DAMAGE ASSESSMENT

Privacy Act Statement

The information requested is necessary to process the subject loss. The authority to collect the information is Title 42, U.S. Code, Section

4001 to 4028. It is voluntary on your part to furnish the information. However, omission of an item may preclude processing of the form. The

information will not be disclosed outside of the Federal Emergency Management Agency, except to the servicing agent, acting as the

government's fiscal agent; to claims adjusters to enable them to confirm coverage and the location of insured property; to certain Federal,

State, and Local Government agencies for determining eligibility for benefits and for verification of agencies for acquisition and relocation-

related projects, consistent with the National Flood Insurance Program and consistent with the routine uses described in the program's system

of record. Failure by you to provide some or all of the information may result in delay in processing or denial of this claim and/or application.

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for the collection of information titled Claims for National Flood Insurance Program (NFIP) is estimated to

average 6 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,

gathering and maintaining the data needed, and completing and submitting these forms. You are not required to respond to this

collection of information unless a currently valid OMB control number and expiration date is displayed in the upper right corner of

the these forms. Send comments regarding the accuracy of the burden estimate and suggestions for reducing the burden to:

Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, S.

W., Washington, DC 20472, Paperwork Reduction Project (1660-0005). NOTE: Do not send your completed form to this address.

Send completed forms to: NFIP Bureau & Statistical Agent, Certification Coordinator, P.O. box 310 , Lanham, MD 20703-0310.

INSURER

DATE OF LOSS

ADJUSTER

FICO NUMBER

This form is to be used for advisory purposes in helping FEMA and communities identify potential substantially damaged buildings. The

adjuster will use "replacement cost" when completing this form; however, the community is required under the National Flood Insurance

Program to use "market value" in determining substantial damage.

PLEASE PRINT LEGIBLY

POLICY HOLDER

POLICY NUMBER

PROPERTY ADDRESS (Include Zip Code)

BUILDING ACTUAL COST VALUE

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE

POLICY HOLDER

POLICY NUMBER

PROPERTY ADDRESS (Include Zip Code)

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE

BUILDING ACTUAL COST VALUE

**This is an estimate of the cost to repair the building to its pre-flood condition.

FEMA FORM 086-0-20 (07/14)

Page 1 of 2

Fema Form 086-0-20 - Adjuster Preliminary Damage Assessment Page 3

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