DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM THE NFIP REQUIRES THAT A PRELIMINARY REPORT BE RECEIVED WITHIN 15 DAYS OF ASSIGNMENT, AND AN INTERIM OR FINAL REPORT NOT LATER THAN EVERY 30 DAYS THEREAFTER. PRELIMINARY REPORT O.M.B. No. 1660-0005 Expires October 31, 2013 See Reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice ENCL. Other 0 Building worksheets ( ) Photographs ( ) Proof of Loss 0 Other 0 Contents worksheets ( ) Narrative ( pp) R/C Proof 0 INSURANCE Program: Insured's Policy 0 Regular 0 Emergency 0 Coverage verified from: Agent's Daily 0 Form: NFIP 0 Dwelling 0 General Property 0 RCBAP 0 Deductible Term to Reserve Coverage $ $ $ RESERVES: $ $ $ ADVANCE PAYMENT REQUESTED? No 0 Yes 0 Building Contents $ $ If yes, Proof of Loss for amount of payment and supporting documentation must be submitted with this report. R I SK Type of Building: Condo Association 0 Single Family 0 2-4 Family 0 Other Residential 0 Non- Residential 0 Condo Unit 0 Mobile Home/Travel Trailer: 0 Make: 0 Model: 0 Occupancy: Residency: Principal 0 Seasonal 0 Owner 0 State government owned 0 Unoccupied 0 Tenant 0 Title Verified? Yes 0 No 0 Source of verification: 0 Number of floors in building including basement: Is building a split level? 3 or more 0 1 0 2 0 Yes 0 No 0 In case of multiple occupancy, indicate floor(s) occupied by insured: Basement 0 First 0 Second and or/above 0 Type of basement: None 0 Unfinished 0 Finished 0 Yes 0 No 0 Foundation area enclosure? Building elevated? None 0 Breakway walls 0 No 0 Yes 0 Unfinished 0 Finished 0 New building 0 No 0 Improvement in progress 0 Is risk under construction? Poor 0 Fair 0 Good 0 Very Good 0 Post Firm 0 Pre Firm 0 Contents: Poor 0 Fair 0 Good 0 Very Good 0 Concrete 0 Steel 0 Wood 0 Other 0 Unreinf. block 0 Reinf. concrete 0 Reinf. block 0 Brick 0 Piers: Reinf. concrete 0 Walls: Wood post 0 Piles: Reinf. concrete shear 0 Treated plywood 0 Block 0 Other 0 Brick 0 Other 0 Concrete slab 0 Exterior wall surface treatment: Unfinished 0 Stone/brick veneer 0 Wood stud 0 Exterior wall structure: Reinf. concrete 0 Concrete bock 0 Wood siding 0 Stucco 0 Metal sheathing/siding 0 Steel and glass 0 Brick or stone 0 Other 0 Vinyl sheathing/siding 0 Other 0 Basement 0 Basement and first floor 0 Contents located in: First floor and above 0 First floor 0 Household 0 Other than household 0 Second floor and above 0 Distance from risk: ORIGI N No: Explain fully under remarks 0 Yes: Indicate cause of loss 0 Cause of loss: Tidal water overflow 0 Alluvial fan overflow 0 Stream, river, or lake overflow 0 Accumulation of rainfall or snowmelt 0 Wave action 0 Low velocity flow or ponding 0 Velocity flow 0 Mudflow 0 Erosion 0 Was flood associated with failure of a dam, storm drain, storm drain system, pump(s), other flood control measure, etc. Yes 0 No 0 Did other than natural cause contribute to flooding? If "yes" to either question, complete "Cause of Loss and Subrogation Report" Yes 0 No 0 Main Building/Condo Assn: Apt. Building/condo Unit: REPLACES ALL PREVIOUS EDITIONS FEMA Form 086-0-13, OCT 2010 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