National Flood Insurance Program Claims Forms

Forms and Documents

Document Name	Status
Form 086-0-06 National Flood Insurance Program Worksheet - Contents - Personal Property Form	Modified
Form 086-0-21 Adjuster Certification Application Form	Modified
Form 086-0-20 Adjuster Preliminary Damage Assessment Form	Modified
Form 086-0-19 Increased Cost of Compliance (ICC) Adjuster Report Form	Modified
Form 086-0-18 Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued) Form	Modified
Form 086-0-17 Manufactured (Mobile) Home/Travel Trailer Worksheet Form	Modified
Form 086-0-16 Cause of Loss and Subrogation Report Form	Modified
Form 086-0-15 National Flood Insurance Program Narrative Report Form	Modified
Form 086-0-14 National Flood Insurance Program Final Report Form	Modified
Form 086-0-13 National Flood Insurance Program Preliminary Report Form	Modified
Form 086-0-12 Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy Form	Modified
Form 086-0-11 Notice of Loss Form	Modified
Form 086-0-10 Increase of Compliance Proof of Loss Form	Modified
Form 086-0-9 Proof of Loss Form	Modified
Form 086-0-08 Worksheet - Building (Continued) Form	Modified
Form 086-0-07 Worksheet - Building Form	Modified
Narrative of Revisions 1660-0005 7-30-10.docx Supplementary Document	2010-07-30
NFIP Claims Handbook.pdf Supplementary Document	2010-07-29
National Flood Insurance Reform Act of 1994.pdf Supplementary Document	2010-07-29
42 USC 4001.pdf Supplementary Document	2010-07-29
60-day FRN published 5-5-10 75fr24728.pdf Supplementary Document	2010-07-29
30-day FRN pub 7-27-10 75fr44002.pdf Supplementary Document	2010-07-27
Supporting Statement 1660-0005 9-28-10.docx Supporting Statement A	2010-09-28

IC Document Collections

IC ID	Document Title	Status
21044	National Flood Insurance Program Worksheet - Contents - Personal Property Form	Modified
180864	Adjuster Certification Application Form	Modified
180862	Adjuster Preliminary Damage Assessment Form	Modified
180861	Increased Cost of Compliance (ICC) Adjuster Report Form	Modified
180859	Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued) Form	Modified
180858	Manufactured (Mobile) Home/Travel Trailer Worksheet Form	Modified
180856	Cause of Loss and Subrogation Report Form	Modified
180855	National Flood Insurance Program Narrative Report Form	Modified
180854	National Flood Insurance Program Final Report Form	Modified
180852	National Flood Insurance Program Preliminary Report Form	Modified
180851	Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy Form	Modified
180849	Notice of Loss Form	Modified
180848	Increase of Compliance Proof of Loss Form	Modified
180847	Proof of Loss Form	Modified
180846	Worksheet - Building (Continued) Form	Modified
180842	Worksheet - Building Form	Modified

ICR Details

OMB Control No: 1660-0005	ICR Reference No: 201007-1660-006
Status: Historical Active	Previous ICR Reference No: 200706-1660-006
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 with change	Conclusion Date: 10/26/2010
	Date Received in OIRA: 08/27/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved	10/31/2010
Responses	29,484	0	42,225
Time Burden (Hours)	20,935	0	29,448
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): US Code: 42 USC 4001 Name of Law: The National Flood Insurance Act of 1968
   PL: Pub.L. 103 - 325 555 Name of Law: National Flood Insurance Reform Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 24728	05/05/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 44002	07/27/2010
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy	086-0-12	Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy
Increased Cost of Compliance (ICC) Adjuster Report	086-0-19	Increased Cost of Compliance (ICC) Adjuster Report
Manufactured (Mobile) Home/Travel Trailer Worksheet	086-0-17	Manufactured (Mobile) Home/Travel Trailer Worksheet
National Flood Insurance Program Worksheet - Contents - Personal Property	086-0-06	National Floos Insurance Program Worksheet - Contents - Personal Property
Adjuster Certification Application	086-0-21	Adjuster Certification Application
Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued)	086-0-18	Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued)
Worksheet - Building	086-0-07	Building - Worksheet
Increase of Compliance Proof of Loss	086-0-10	Increase Of Compliance Proof of Loss
Notice of Loss	086-0-11	Notice of Loss
National Flood Insurance Program Preliminary Report	086-0-13	National Flood Insurance Program Preliminary Report
National Flood Insurance Program Narrative Report	086-0-15	National Flood Insurance Program Narrative Report
National Flood Insurance Program Final Report	086-0-14	National Flood Insurance Program Final Report
Worksheet - Building (Continued)	086-0-08	NFIP Worksheet Building
Cause of Loss and Subrogation Report	086-0-16	Cause of Loss and Subrogation Report
Adjuster Preliminary Damage Assessment	086-0-20	Adjuster Preliminary Damage Assessment
Proof of Loss	086-0-9	Proof of Loss

---

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	29,484	42,225	0	0	-12,741	0
Annual Time Burden (Hours)	20,935	29,448	0	0	-8,513	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: The prior PRA submission included calculations based on the catastrophic events Hurricanes Katrina and Rita. Disaster activity has decreased to more historically normal levels and the new annual burden hours reflect this. The Annual Hour Burden at the time of the last PRA submission was 29,448, the new Annual Hour Burden is 20,935.2 and the net decrease is -8,512.8 hours.

---

Annual Cost to Federal Government: $5,303,786

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 08/27/2010

---