Form 81-42 Proof of Loss

POLICY NO. FL

O.M.B. No. 1660-0005
Expires JUNE 30, 2007

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM

POLICY TERM

PROOF OF LOSS

(See reverse side for Privacy Act Statement
and Paperwork Burden Disclosure Notice)

AMT OF BLDG COV AT TIME OF LOSS

AGENT

AMT OF CNTS COV AT TIME OF LOSS

AGENCY AT

TO THE NATIONAL FLOOD INSURANCE PROGRAM:
At time of loss, by the above indicated policy of insurance, you insured the interest of

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

A
on the

OCCUPANCY

loss occurred about the hour of
day of

20

o'clock

M.,

. The cause of the said loss was:

The premises described, or containing the property described, was occupied at the time of the loss as follows, and for
no other purpose whatever:

INTEREST

No other person or persons had any interest therein or encumbrance thereon except

1. FULL AMOUNT OF INSURANCE application to the property for which claim is presented is ......................

$

2. ACTUAL CASH VALUE of building structures ....................................................................................

$

3. ADD ACTUAL CASH VALUE OF CONTENTS of personal property insured .............................................

$

4. ACTUAL CASH VALUE OF ALL PROPERTY .......................................................................................

$

5. FULL COST OF REPAIR OR REPLACEMENT (Building and Contents) .....................................................

$

6. LESS APPLICABLE DEPRECIATION ...................................................................................................

$

7. ACTUAL CASH VALUE LOSS is .......................................................................................................

$

8. LESS DEDUCTIBLES .......................................................................................................................

$

9. NET AMOUNT CLAIMED under above numbered policy is ...................................................................

$

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 your 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 an willfully making any false
answers or misrepresentations of fact may be punishable by fine or imprisonment under applicable United States Codes.
Subrogation - To the extent of the payment made or advanced under this policy; the insured hereby assigns, transfers and sets over to 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.
State of
County of
Insured
Subscribed and sworn before me this

day of

, 20

Notary Public
FEMA Form 81-42, JUL 04

REPLACES ALL PREVIOUS EDITIONS.

F-101 (7/04)

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 4 hours per claim. This estimate includes the time, effort, or financial resources expended by persons to generate, maintain,
retain, disclose, or provide information to the Mitigation Division or its agent. The reporting burden for this form as part of the
collection of information is highlighted below. 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 highlighted form. You may send comments
regarding the accuracy of the burden estimate and suggestions for reducing the burden to: Information Collections Management, U.S.
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.
81-40
81-41
81-41A
81-42
81-42A
81-43
81-44

81-57
81-58
81-59
81-63
81-96
81-98

Title
Worksheet-Contents-Personal Property
Worksheet-Building
Worksheet-Building (Cont'd)
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
National Flood Insurance Program Preliminary Report
National Flood Insurance Program Final Report
National Flood Insurance Program Narrative Report
Cause of Loss and Subrogation Report
Mobile Home Worksheet
Increased Cost of Compliance (ICC) Adjuster Report

Burden Hours
2.5 Hours
2.5 Hours
1.0 Hours
5 Minutes
2.0 Hours
4 Minutes
6 Minutes

4 Minutes
4 Minutes
5 Minutes
1 Hour
30 Minutes
25 Minutes