U.S. DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. NO. 1660-0006 Expires August 31, 2013 National Flood Insurance Program PART 1 (OF 2) OF FLOOD INSURANCE APPLICATION NFIP COPY AGENT COPY INSURED COPY MORTGAGEE CERTIFICATION COPY CURRENT POLICY NUMBER NEW RENEWAL IMPORTANT—PLEASE PRINT OR TYPE POLICY TERM DIRECT BILL INSTRUCTIONS: BILL INSURED BILL FIRST MORTGAGEE BILL LOSS PAYEE BILL SECOND MORTGAGEE BILL OTHER POLICY PERIOD IS FROM ___ TO ___ 12:01 A.M LOCAL TIME AT THE INSURED PROPERTY LOCATION WAITING PERIOD: STANDARD 30-DAY MAP REVISION (ZONE CHANGE FROM NON-SFHA TO SFHA)—ONE DAY LOAN TRANSACTION—NO WAITING LENDER REQUIRED—NO WAITING (SFHA ONLY) AGENT AGENT INFORMATION NAME, ADDRESS OF LICENSED PROPERTY OR CASUALTY INSURANCE AGENT OR BROKER: AGENCY NO.: AGENT’S TAX ID: PHONE NO.: FAX NO.: INSURED INSURED MAILING ADDRESS NAME, MAILING ADDRESS, AND PHONE NO. OF INSURED: PHONE NO.: MORTGAGEE NAME AND ADDRESS OF FIRST MORTGAGEE: LOAN NO.: PHONE NO.: FAX NO.: 2ND MORTGAGEE/OTHER IF SECOND MORTGAGEE, LOSS PAYEE OR OTHER IS TO BE BILLED, COMPLETE THE FOLLOWING, INCLUDING THE NAME AND ADDRESS: 2ND MORTGAGEE DISASTER AGENCY LOSS PAYEE IF OTHER, PLEASE SPECIFY: LOAN NO.: PHONE NO.: FAX NO.: COMMUNITY RATING MAP INFORMATION NAME OF COUNTY/PARISH: COMMUNITY NO./PANEL NO. AND SUFFIX: — FIRM ZONE: COMMUNITY PROGRAM TYPE IS: REGULAR EMERGENCY GRANDFATHERED? YES NO IF YES, BUILT IN COMPLIANCE? CONTINUOUS COVERAGE? PRIOR POLICY NO.: CURRENT COMMUNITY NO./PANEL NO. AND SUFFIX: — CURRENT FIRM ZONE: CURRENT BFE: 2ND MORTGAGEE IS INSURED BUILDING OWNED BY STATE GOVERNMENT? YES NO IS BUILDING LOCATED ON FEDERAL LAND? YES NO BUILDING OCCUPANCY SINGLE FAMILY 2-4 FAMILY OTHER RESIDENTIAL NON-RESIDENTIAL (INCLUDING HOTEL/MOTEL) BASEMENT, ENCLOSURE, CRAWLSPACE NONE FINISHED BASEMENT/ENCLOSURE UNFINISHED BASEMENT/ENCLOSURE CRAWLSPACE SUBGRADE CRAWLSPACE NUMBER OF FLOORS IN ENTIRE BUILDING (INCLUDE BASEMENT/ENCLOSED AREA, IF ANY) OR BUILDING TYPE 1 2 3 OR MORE SPLIT LEVEL TOWNHOUSE/ROWHOUSE (RCBAP LOW-RISE ONLY) MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER ON FOUNDATION IF NOT A SINGLE-FAMILY DWELLING, NUMBER OF OCCUPANCIES (UNITS) IS: CONDO FORM OF OWNERSHIP? YES NO CONDO COVERAGE IS FOR: UNIT ENTIRE BUILDING RESIDENTIAL CONDOMINIUM BUILDING ASSOCIATION POLICY ONLY: TOTAL NUMBER OF UNITS: (INCLUDE NON-RES.) HIGH-RISE LOW-RISE ESTIMATED REPLACEMENT COST AMOUNT $ IS BUILDING INSURED’S PRINCIPAL RESIDENCE? YES NO IS BUILDING IN THE COURSE OF CONSTRUCTION? YES NO IS BUILDING WALLED AND ROOFED? YES NO IS BUILDING OVER WATER? NO PARTIALLY ENTIRELY IS BUILDING ELEVATED? YES NO IF YES, AREA BELOW IS: FREE OF OBSTRUCTION WITH OBSTRUCTION IF ELEVATED, COMPLETE PART 2 OF APPLICATION BUILDING USE: MAIN HOUSE/BUILDING DETACHED GUEST HOUSE DETACHED GARAGE AGRICULTURAL BUILDING WAREHOUSE POOLHOUSE, CLUBHOUSE, RECREATION BUILDING TOOL/STORAGE SHED OTHER: FOR MANUFACTURED (MOBILE) HOMES/TRAVEL TRAILERS, COMPLETE PART 2, SECTION III. CONTENTS CONTENTS LOCATED IN: BASEMENT/ENCLOSURE BASEMENT/ENCLOSURE AND ABOVE LOWEST FLOOR ONLY ABOVE GROUND LEVEL LOWEST FLOOR ABOVE GROUND LEVEL AND HIGHER ABOVE GROUND LEVEL MORE THAN ONE FULL FLOOR (IF SINGLE FAMILY, CONTENTS ARE RATED THROUGHOUT THE BUILDING) IS PERSONAL PROPERTY HOUSEHOLD CONTENTS? YES NO IF NO, PLEASE DESCRIBE: CONSTRUCTION DATA DATE: _______/_______/_______ (MM/DD/YYYY) ALL BUILDINGS: (CHECK ONE OF THE FIVE BLOCKS AND RECORD CORRESPONDING DATE IN THE DATE BOX) BUILDING PERMIT DATE DATE OF CONSTRUCTION SUBSTANTIAL IMPROVEMENT DATE MANUFACTURED (MOBILE) HOMES/TRAVEL TRAILERS LOCATED IN A MOBILE HOME PARK OR SUBDIVISION: CONSTRUCTION DATE OF MOBILE HOME PARK OR SUBDIVISION FACILITIES MANUFACTURED (MOBILE) HOMES/TRAVEL TRAILERS LOCATED OUTSIDE A MOBILE HOME PARK OR SUBDIVISION: DATE OF PERMANENT PLACEMENT IS BUILDING POST-FIRM CONSTRUCTION? YES NO IF POST-FIRM CONSTRUCTION IN ZONES A, A1-A30, AE, AO, AH, V, V1-V30, VE, OR IF PRE-FIRM CONSTRUCTION IS ELEVATION RATED, ATTACH CERTIFICATION. BUILDING DIAGRAM NO.: LOWEST ADJACENT GRADE (LAG): ELEVATION CERTIFICATION DATE: LOWEST FLOOR ELEVATION (–) BASE FLOOD ELEVATION (=) DIFFERENCE TO NEAREST FOOT (+ OR –) IN ZONES V AND V1-V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION? YES NO IS BUILDING FLOODPROOFED? YES NO (SEE NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.) COVERAGE AND RATING DEDUCTIBLE: BUILDING $ CONTENTS $ DEDUCTIBLE BUYBACK? YES NO COVERAGE BASIC LIMITS ADDITIONAL LIMITS (REGULAR PROGRAM ONLY) DEDUCTIBLE BASIC AND ADDITIONAL TOTAL PREMIUM AMOUNT OF INSURANCE RATE ANNUAL PREMIUM AMOUNT OF INSURANCE RATE ANNUAL PREMIUM PREM. REDUCTION/ INCREASE TOTAL AMOUNT OF INSURANCE BUILDING .00 .00 .00 .00 CONTENTS .00 .00 .00 .00 RATE TYPE: (ONE BUILDING PER POLICY—BLANKET COVERAGE NOT PERMITTED) MANUAL SUBMIT FOR RATING ALTERNATIVE V-ZONE RISK FACTOR RATING FORM PROVISIONAL RATING LEASED FEDERAL PROPERTY MORTGAGE PORTFOLIO PROTECTION PROGRAM PAYMENT OPTION: CREDIT CARD OTHER: ANNUAL SUBTOTAL $ ICC PREMIUM SUBTOTAL CRS PREMIUM DISCOUNT % THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE FEDERAL LAW. SEE REVERSE SIDE OF COPIES 2, 3, & 4. SUBTOTAL PROBATION SURCHARGE + FEDERAL POLICY FEE + TOTAL PREPAID AMOUNT $ SIGNATURE THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE FEDERAL LAW. SEE REVERSE SIDE OF COPIES 2, 3, & 4. SIGNATURE OF INSURANCE AGENT/BROKER DATE (MM/DD/YYYY) FEMA FORM 086-0-1, AUG 10 PREVIOUSLY FEMA FORM 81-16 F-050 (8/10) PLEASE ATTACH TO NFIP COPY OF APPLICATION THE CHECK OR MONEY ORDER FOR THE TOTAL PREPAID PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP — IMPORTANT U.S. DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY National Flood Insurance Program O.M.B. NO. 1660-0006 Expires August 31, 2013 PART 2 (OF 2) OF FLOOD INSURANCE APPLICATION ALL APPROPRIATE DATA PROVIDED BY THE INSURED OR OBTAINED FROM THE ELEVATION CERTIFICATE SHOULD BE REVIEWED AND TRANSCRIBED BELOW. THIS PART OF THE APPLICATION MUST BE COMPLETED FOR ALL BUILDINGS. CURRENT POLICY NUMBER NEW RENEWAL SECTION I—ALL BUILDING TYPES 1. DIAGRAM NUMBER SELECTED FROM BUILDING DIAGRAMS 1-9: 2. THE LOWEST FLOOR IS (ROUND TO NEAREST FOOT): FEET ABOVE BELOW (CHECK ONE) THE LOWEST GROUND (GRADE) IMMEDIATELY NEXT TO THE BUILDING. 3. THE GARAGE FLOOR (IF APPLICABLE) OR ELEVATED FLOOR (IF APPLICABLE) IS (ROUND TO NEAREST FOOT): FEET ABOVE BELOW (CHECK ONE) THE LOWEST GROUND (GRADE) IMMEDIATELY NEXT TO THE BUILDING. 4. MACHINERY OR EQUIPMENT LOCATED AT A LEVEL LOWER THAN THE LOWEST FLOOR IS (ROUND TO NEAREST FOOT): FEET BELOW THE LOWEST FLOOR. 5. SITE LOCATION A) APPROXIMATE DISTANCE OF SITE LOCATION TO NEAREST SHORELINE: LESS THAN 200 FEET 500 TO 1,000 FEET 200 TO 500 FEET MORE THAN 1,000 FEET B) SOURCE OF FLOODING: OCEAN RIVER/STREAM LAKE OTHER: 6. BASEMENT/SUBGRADE CRAWLSPACE A) IS THE BASEMENT/SUBGRADE CRAWLSPACE FLOOR BELOW GRADE ON ALL SIDES? YES NO B) DOES THE BASEMENT/SUBGRADE CRAWLSPACE CONTAIN MACHINERY OR EQUIPMENT? YES NO IF YES, CHECK THE APPROPRIATE ITEMS: FURNACE HEAT PUMP AIR CONDITIONER HOT WATER HEATER FUEL TANK CISTERN ELEVATOR EQUIPMENT WASHER & DRYER FOOD FREEZER OTHER EQUIPMENT OR MACHINERY SERVICING THE BUILDING 7. GARAGE A) IS THE GARAGE ATTACHED TO OR PART OF THE BUILDING? YES NO B) TOTAL AREA OF THE GARAGE: SQUARE FEET. C) ARE THERE ANY OPENINGS (EXCLUDING DOORS) THAT ARE DESIGNED TO ALLOW THE PASSAGE OF FLOODWATERS THROUGH THE GARAGE? YES NO IF YES, NUMBER OF PERMANENT OPENINGS (FLOOD VENTS) WITHIN 1 FOOT ABOVE THE ADJACENT GRADE: . TOTAL AREA OF ALL PERMANENT OPENINGS (FLOOD VENTS): SQUARE INCHES. D) IS THE GARAGE USED SOLELY FOR PARKING OF VEHICLES, BUILDING ACCESS, AND/OR STORAGE? YES NO E) DOES THE GARAGE CONTAIN MACHINERY OR EQUIPMENT? YES NO IF YES, CHECK THE APPROPRIATE ITEMS: FURNACE HEAT PUMP AIR CONDITIONER HOT WATER HEATER FUEL TANK CISTERN ELEVATOR EQUIPMENT WASHER & DRYER FOOD FREEZER OTHER EQUIPMENT OR MACHINERY SERVICING THE BUILDING F) DOES THE GARAGHAVE MORE THAN 20 LINEAR FEET OF FINISHED WALL, PANELING, ETC? YES NO SECTION II—ELEVATED BUILDINGS (INCLUDING MANUFACTURED [MOBILE] HOMES/TRAVEL TRAILERS) 8. ELEVATING FOUNDATION OF THE BUILDING: PIERS, POSTS, OR PILES REINFORCED MASONRY PIERS OR CONCRETE PIERS OR COLUMNS REINFORCED CONCRETE SHEAR WALLS SOLID PERIMETER WALLS (NOTE: NOT APPROVED FOR ELEVATING IN ZONES V1-V30, VE, OR V.) 9. DOES THE AREA BELOW THE ELEVATED FLOOR CONTAIN MACHINERY OR EQUIPMENT? YES NO IF YES, CHECK THE APPROPRIATE ITEMS: FURNACE HEAT PUMP AIR CONDITIONER HOT WATER HEATER FUEL TANK CISTERN ELEVATOR EQUIPMENT WASHER & DRYER FOOD FREEZER OTHER EQUIPMENT OR MACHINERY SERVICING THE BUILDING 10. AREA BELOW THE ELEVATED FLOOR: A) IS THE AREA BELOW THE ELEVATED FLOOR ENCLOSED? YES NO IF YES, CHECK ONE OF THE FOLLOWING: PARTIALLY FULLY IF 10A IS NO, DO NOT ANSWER 10B THROUGH 10F. B) IF ENCLOSED, PROVIDE SIZE OF ENCLOSED AREA/CRAWLSPACE: SQUARE FEET. C) IS THE AREA BELOW THE ELEVATED FLOOR ENCLOSED USING MATERIALS OTHER THAN INSECT SCREENING OR LIGHT WOOD LATTICE? YES NO IF YES, CHECK ONE OF THE FOLLOWING: BREAKAWAY WALLS SOLID WOOD FRAME WALLS MASONRY WALLS OTHER: D) IS THE ENCLOSED AREA/CRAWLSPACE CONSTRUCTED WITH OPENINGS (EXCLUDING DOORS) TO ALLOW THE PASSAGE OF FLOODWATERS THROUGH THE ENCLOSED AREA? YES NO IF YES, NUMBER OF PERMANENT OPENINGS (FLOOD VENTS) WITHIN 1 FOOT ABOVE ADJACENT GRADE . TOTAL AREA OF ALL PERMANENT OPENINGS (FLOOD VENTS) SQUARE INCHES E) IS THE ENCLOSED AREA/CRAWLSPACE USED FOR ANY PURPOSE OTHER THAN SOLELY FOR PARKING OF VEHICLES, BUILDING ACCESS, OR STORAGE? YES NO IF YES, DESCRIBE: F) DOES THE ENCLOSED AREA/CRAWLSPACE HAVE MORE THAN 20 LINEAR FEET OF FINISHED WALL, PANELING, ETC.? YES NO SECTION III—MANUFACTURED (MOBILE) HOMES/TRAVEL TRAILERS 11. MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER DATA: MAKE: YEAR OF MANUFACTURE: MODEL NUMBER: SERIAL NUMBER: 12. MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER DIMENSIONS: X FEET. 13.ARE THERE ANY PERMANENT ADDITIONS OR EXTENSIONS TO THE MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER? YES NO IF YES, THE DIMENSIONS ARE:XFEET. 14. THE MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER ANCHORING SYSTEM UTILIZES: OVER-THE-TOP TIES GROUND ANCHORS FRAME TIES SLAB ANCHORS FRAME CONNECTORS OTHER: 15. THE MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER WAS INSTALLED IN ACCORDANCE WITH: MANUFACTURER’S SPECIFICATIONS LOCAL FLOODPLAIN MANAGEMENT STANDARDS STATE AND/OR LOCAL BUILDING STANDARDS 16. IS THE MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER LOCATED IN A MANUFACTURED (MOBILE) HOME PARK/SUBDIVISION? YES NO THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE FEDERAL LAW. SIGNATURE OF INSURANCE AGENT/BROKER FEMA FORM 086-0-1, AUG 10 PREVIOUSLY FEMA FORM 81-16 F-050 (8/10) FLOOD INSURANCE FLOOD INSURANCE APPLICATION FEMA FORM 086-0-1 NONDISCRIMINATION No person or organization shall be excluded from participation in, denied the benefits of, or subjected to discrimination under the Program authorized by the Act, on the grounds of race, color, creed, sex, age or national origin. PRIVACY ACT The information requested is necessary to process your Flood Insurance Application for a flood insurance policy. The authority to collect the information is Title 42, U.S. Code, Sections 4001 to 4028. Disclosures of this information may be made: to federal, state, tribal, and local government agencies, fiscal agents, your agent, mortgage servicing companies, insurance or other companies, lending institutions, and contractors working for us, for the purpose of carrying out the National Flood Insurance Program; to current Severe Repetitive Loss property owners and Preferred Risk Policy owners for the purpose of property loss history evaluation; to the American Red Cross for verification of nonduplication of benefits following a flooding event or disaster; to law enforcement agencies or professional organizations when there may be a violation or potential violation of law; to a federal, state or local agency when we request information relevant to an agency decision concerning issuance of a grant or other benefit, or in certain circumstances when a federal agency requests such information for a similar purpose from us; to a Congressional office in response to an inquiry made at the request of an individual; to the Office of Management and Budget (OMB) in relation to private relief legislation under OMB Circular A-19; and to the National Archives and Records Administration in records management inspections. Providing the information is voluntary, but failure to do so may delay or prevent issuance of the flood insurance policy. GENERAL This information is provided pursuant to Public Law 96-511 (Paperwork Reduction Act of 1980, as amended), dated December 11, 1980, to allow the public to participate more fully and meaningfully in the Federal paperwork review process. AUTHORITY Public Law 96-511, amended, 44 U.S.C. 3507; and 5 CFR 1320. PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this data collection is estimated to average 12 minutes 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 this form. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0006). NOTE: Do not send your completed form to this address.