DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY NOTICE OF LOSS NATIONAL FLOOD INSURANCE PROGRAM O.M.B. No. 1660-0005 Expires October 31, 2013 (See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice) 10. KIND OF LOSS Flood 0 Mudslide 0 11. Probable Amount of Loss-All Perils 12. Estimate of Loss-this Policy $ 13. KIND OF LOSS Yes 0 No 0 Buildings 0 Contents 0 15. DESCRIPTION OF PROPERTY COVERED ITEM NO. AMOUNT INSURANCE DESCRIPTION 1 Bldg. $ on the Family Story building of Basement Yes 0 No 0 2 Conts. On the contents in the Building described above or in the 0 Construction. Basement Yes 0 No 0 19. COPIES SENT TO The Standard Flood Insurance Policy is subject to the National Flood Insurance Act of 1968, and any Acts Amendatory thereof, and Regulations issued by the Federal Insurance Administration pursuant to such statute(s). FEMA Form 086-0-11, OCT 2010 REPLACES ALL PREVIOUS EDITIONS F-102 INSTRUCTIONS FOR AGENTS OR BROKERS 1. Complete this Notice of Loss in its entirety. DO NOT OMIT ANY INFORMATION. 2. Forward the completed notice to NFIP shown on the Declarations Sheet of the Policy. 3. All losses under Flood Policies will b e assigned to adjusters by NFIP. 4. Agents and Brokers are not permitted to adjust losses under Flood Policies. 5. Additional Flood Notices of Loss may be obtained from: FEMA/MAP Services Center P.O. Box 1038 Jessup, MD 20794-1038 1-800-358-9616 INSTRUCTIONS FOR ADJUSTERS: 1. Obtain necessary forms for the adjustment of Flood Losses from NFIP assigning the loss. 2. Preliminary reports and estimates must be submitted to NFIP not later than ten working days from the date of assignment. 3. Preliminary reports must indicate the height of the water, to the nearest foot, above or below the first floor level of the risk involved. 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. FEMA Form No. Title Burden Hours 086-0-6 Worksheet-Contents-Personal Property 2.5 Hours 086-0-7 Worksheet-Building 2.5 Hours 086-0-8 Worksheet-Building (Continued) 1 Hours 086-0-9 Proof of Loss .08 Hours 086-0-10 Increased Cost of Compliance 2 Hours 086-0-11 Notice of Loss .07 Hours 086-0-12 Statement as to Full Cost to Repair or Replacement .10 Hours Cost Coverage, Subject to the Terms and Conditions of this Policy 086-0-13 National Flood Insurance Program Preliminary Report .07 Hours 086-0-14 National Flood Insurance Program Final Report .07 Hours 086-0-15 National Flood Insurance Program Narrative Report .08 Hours 086-0-16 Cause of Loss and Subrogation Report 1 Hour 086-0-17 Manufactured (Mobile) Home/Travel Trailer Worksheet .50 Hours 086-0-18 Mobile Home/Travel Trailer Worksheet (Continued) .25 Hours 086-0-19 Increased Cost of Compliance (ICC) Adjuster Report .42 Hours 086-0-20 Adjuster Preliminary Damage Assessment .25 Hours 086-0-21 Adjuster Certification Application .25 Hours