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Get FEMA 086-0-6 2014

M. B. No. 1660-0005 Expires April 30 2017 DATE OF REPORT INSURED AND LOCATION POLICY NO. FL ADJUSTER ADJUSTING FIRM AND ADDRESS Item FEMA Form 086-0-6 04/14 Adjuster s File No. Date of Loss Description Quantity Age Replacement Cost Loss or Damage Depreciation A. NOTE Do not send your completed form to this address. FEMA Form No. 086-0-6 086-0-10 Title Worksheet-Contents-Personal Property Worksheet-Building Proof of Loss Increased Cost of Compliance Notice of Loss Statement as to Full Cost to Repair or Replacement Cost Coverage Subject to the Terms and Conditions of this Policy Cause of Loss and Subrogation Report Manufactured Mobile Home/Travel Trailer Worksheet Mobile Home/Travel Trailer Worksheet Continued Adjuster Preliminary Damage Assessment Adjuster Certification Application Burden Hours 2. National Flood Insurance Program See Privacy Act Statement and Paperwork Burden Disclosure Notice on reverse DEPARTMENT OF HOMELAND SECURITY FEDERAL EMERGENCY MANAGEMENT AGENCY WORKSHEET - CONTENTS - PERSONAL PROPERTY O. C. V. Flood Loss Wind Loss 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 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. C. V. Flood Loss Wind Loss 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 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. .

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