National Flood Insurance Program Claims Forms

Forms and Documents

Document Name	Status
Form 81-40 Worksheet Contents Personal Property Form	Modified
Form 81-110 Adjuster Certification Application 81-110 Form	New
Form 81-109 Adjuster Preliminary Damage Assessment 81-109 Form	New
Form 81-98 Increased Cost of Compliance (ICC) Adjuster Report 81-98 Form	New
Form 81.96 A Mobile Home Worksheet Con'td 81-96A Form	New
Form 81-96 Mobile Home Worksheet Form	New
Form 81-63 Cause of Loss and Subrogation Report 81-63 Form	New
Form 81-59 NFIP Narrative Report 81-59 Form	New
Form 81-58 NFIP Final Report 81-58 Form	New
Form 81-57 NFIP Preliminary Report 81-57 Form	New
Form 81-44 NFIP Statement of Full Cost or Replacement 81-44 Form	New
Form 81-43 Notice of Loss 81-43 Form	New
Form 81-42A Increase of Compliance Proof of Loss 81-42A Form	New
Form 81-42 Proof of Loss 81-42 Form	New
Form 81-41A NFIP Worksheet Building 81-41A Form	New
Form 81-41 NFIP Worksheet - Building 81-41 Form	New
United States Public Laws.doc Supplementary Document	2007-06-26
Sec 205 (PL 108-264).doc Supplementary Document	2007-06-26
44 CFR Part 61 5.24.07 A. Flynt.pdf Supplementary Document	2007-06-26
42 USCA ss 4011 5.24.07 A. Flynt.pdf Supplementary Document	2007-06-26
1660-0005 Supporting Statement FINAL.doc Supporting Statement A	2007-06-26
NFIP Flood Insurance Claims Handbook A.Flynt.pdf Supplementary Document	2007-06-26
Pub. 30d FRN 6.20.07 A. Flynt.pdf Supplementary Document	2007-06-26
Pub 60d FRN 4.20.07 A. Flynt.pdf Supplementary Document	2007-06-26

IC Document Collections

IC ID	Document Title	Status
21044	Worksheet Contents Personal Property Form	Modified
180864	Adjuster Certification Application 81-110 Form	New
180862	Adjuster Preliminary Damage Assessment 81-109 Form	New
180861	Increased Cost of Compliance (ICC) Adjuster Report 81-98 Form	New
180859	Mobile Home Worksheet Con'td 81-96A Form	New
180858	Mobile Home Worksheet Form	New
180856	Cause of Loss and Subrogation Report 81-63 Form	New
180855	NFIP Narrative Report 81-59 Form	New
180854	NFIP Final Report 81-58 Form	New
180852	NFIP Preliminary Report 81-57 Form	New
180851	NFIP Statement of Full Cost or Replacement 81-44 Form	New
180849	Notice of Loss 81-43 Form	New
180848	Increase of Compliance Proof of Loss 81-42A Form	New
180847	Proof of Loss 81-42 Form	New
180846	NFIP Worksheet Building 81-41A Form	New
180842	NFIP Worksheet - Building 81-41 Form	New

ICR Details

OMB Control No: 1660-0005	ICR Reference No: 200706-1660-006
Status: Historical Active	Previous ICR Reference No: 200402-1660-004
Agency/Subagency: DHS/FEMA	Agency Tracking No:
Title: National Flood Insurance Program Claims Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/20/2007
	Date Received in OIRA: 06/28/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2010	36 Months From Approved	09/30/2007
Responses	42,225	0	27,970
Time Burden (Hours)	29,448	0	20,134
Cost Burden (Dollars)	0	0	0

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Abstract: The Claims Forms used for the National Flood Insurance Program are used by policyholders and adjusters to collect the information needed to investigate, document, evaluate, and settle claims against National Flood Insurance Program policies for flood damage to their insured property or qualification for benefits under Increased Cost of Compliance coverage.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 19943	04/20/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 34031	06/20/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 16

IC Title	Form No.	Form Name
NFIP Worksheet - Building 81-41	81-41	NFIP Building Worksheet
Increase of Compliance Proof of Loss 81-42A	81-42A	Increase Of Compliance Proof of Loss
Notice of Loss 81-43	81-43	Notice of Loss
NFIP Preliminary Report 81-57	81-57	NFIP Preliminary Report
NFIP Narrative Report 81-59	81-59	NFIP Narrative Report
NFIP Final Report 81-58	81-58	NFIP Final Report
NFIP Worksheet Building 81-41A	81-41A	NFIP Worksheet Building
Cause of Loss and Subrogation Report 81-63	81-63	Cause of Loss and Subrogation Report
Adjuster Preliminary Damage Assessment 81-109	81-109	Adjuster Preliminary Damage Assessment
Proof of Loss 81-42	81-42	Proof of Loss
Mobile Home Worksheet Con'td 81-96A	81.96 A	NFIP Mobile Home Worksheet cont.
NFIP Statement of Full Cost or Replacement 81-44	81-44	NFIP Statement of Full Cost or Replacement
Increased Cost of Compliance (ICC) Adjuster Report 81-98	81-98	Increased Cost of Compliance Adjuster Report
Mobile Home Worksheet	81-96	Mobile Home Worksheet
Worksheet Contents Personal Property	81-40	Worksheet Contents Personal Property
Adjuster Certification Application 81-110	81-110	Adjuster Certification Application

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	42,225	27,970	0	0	14,255	0
Annual Time Burden (Hours)	29,448	20,134	0	0	9,314	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $9,000,853

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/28/2007

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