DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM PROOF OF LOSS O.M.B. No. 1660-0005 Expires October 31, 2013 OCCUPANCY The premises described, or containing the property described, was occupied at the time of the loss as follows, and for no other purpose whatever: day of , 20 FEMA Form 086-0-9, (10/10) REPLACES ALL PREVIOUS EDITIONS F-101 The said loss did not originate by any act, design or procurement on the part of your insured, nothing has been done by or with the privity or consent of insured to violate the conditions of the policy, or render it void; no articles are mentioned herein or in annexed schedules but such as were destroyed or damaged at the time of said loss, no property saved has in any manner been concealed, and no attempt to deceive the said insurer as to the extent of said loss, has in any manner been made. Any other information that may be required will be furnished and considered a part of this proof. I understand that this insurance (policy) is issued Pursuant to the National Flood Insurance Act of 1968, or Any Act Amendatory thereof, and Applicable Federal Regulations in Title 44 of the Code of Federal Regulations, Subchapter B, and that knowingly and willfully making any false answers or misrepresentations of fact may be punishable by fine of imprisonment under applicable United State Codes. Subrogation - To the extent of the payment made or advanced under this policy; the insured hereby assigns, transfers and sets over the insurer all rights,claims or interest that he has against any person, firm or corporation liable for the loss or damage to the property for which payment is made or advanced. He also hereby authorizes the insurer to sue any such third party in his name. The insured hereby warrants that no release has been given or will be given or settlement or compromise made or agreed upon with any third party who may be liable in damages to the insured with respect to the claim being made herein. The furnishing of this blank or the preparation of proofs by a representative of the above insurer is not a waiver of any of its rights. I declare under penalty of perjury that the information contained in the foregoing is true and correct to the best of my knowledge and belief. (See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice) M., day of . The cause of said loss was: INTEREST No other person or persons had any interest therein or encumbrance thereon except against loss by flood to the property described according to the terms and conditions of said policy and of all forms, endorsements, transfers and assignments attached thereto. TIME AND ORIGIN. 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