Fema Form 086 0 1 – Fill Out and Use This PDF

National Flood Insurance Program

FLOOD INSURANCE APPLICATION, PAGE 1 (OF 2)

IMPORTANT—PLEASE PRINT OR TYPE; ENTER DATES AS MM/DD/YYYY.

NEW RENEWAL TRANSFER (NFIP ONLY)

PRIOR POLICY #:

BILLING	FOR RENEWAL, BILL:
	INSURED				LOSS PAYEE
	FIRST MORTGAGEE				OTHER (AS SPECIFIED IN THE “2ND
	SECOND MORTGAGEE				MORTGAGEE/OTHER” BOX BELOW)
	NAME AND MAILING ADDRESS OF AGENT/PRODUCER:
AGENT/PRODUCER INFORMATION	AGENCY NO.:				AGENT’S TAX ID:
	PHONE NO.:					FAX NO.:
	EMAIL ADDRESS:

NOTE: ONE BUILDING PER POLICY — BLANKET COVERAGE NOT PERMITTED.

IS INSURED PROPERTY LOCATION SAME AS INSURED’S MAILING ADDRESS? YES NO IF NO, ENTER PROPERTY ADDRESS. IF RURAL, ENTER LEGAL DESCRIPTION, OR GEOGRAPHIC LOCATION OF PROPERTY (DO NOT USE P.O. BOX).

IDENTIFY ADDRESS TYPE: STREET LEGAL DESCRIPTION* GEOGRAPHIC LOCATION LOCATIONPROPERTY FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR

EXTENSIONS, DESCRIBE THE INSURED BUILDING:

*LEGAL DESCRIPTION MAY BE USED ONLY WHILE A BUILDING OR SUBDIVISION IS IN THE COURSE OF CONSTRUCTION OR PRIOR TO ESTABLISHING A STREET ADDRESS.

DISASTER ASSISTANCE

CASE FILE NO.:

IS INSURANCE REQUIRED FOR DISASTER ASSISTANCE?

YES

NO

IF YES, CHECK THE GOVERNMENT AGENCY:

SBA

FEMA

FHA

OTHER (SPECIFY):

GRANDFATHERING INFORMATION

GRANDFATHERED?

YES

NO

IF YES,

BUILT IN COMPLIANCE OR

CONTINUOUS COVERAGE (PROVIDE PRIOR POLICY NUMBER IN BOX ABOVE)

COMMUNITY

RATING MAP INFORMATION

NAME OF COUNTY/PARISH:

COMMUNITY NO./PANEL NO. AND SUFFIX:

–

FIRM ZONE:

MAP DATE:

/

/

COMMUNITY PROGRAM TYPE IS:

REGULAR

EMERGENCY

CURRENT MAP INFORMATION

CURRENT COMMUNITY NO./PANEL NO. AND SUFFIX:

–

CURRENT FIRM ZONE:

CURRENT BFE:

MAP DATE:

/

/

POLICY PERIOD IS FROM

/

/

TO

/

/

PERIOD

STANDARD 30-DAY

12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.

POLICY

WAITING PERIOD:

REQUIRED FOR LOAN TRANSACTION — NO WAITING PERIOD

MAP REVISION (ZONE CHANGE FROM NON-SFHA TO SFHA) — 1 DAY

TRANSFER (NFIP ONLY) — NO WAITING PERIOD

INDICATE THE PROPERTY PURCHASE DATE:

/

/

NAME AND MAILING ADDRESS OF INSURED:

INSURED INFORMATION

PHONE NO.:

IS THE INSURED A SMALL BUSINESS?

YES

NO

IS THE INSURED A NON-PROFIT ENTITY?

YES

NO

NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:

1ST MORTGAGEE

LOAN NO.:

IS INSURANCE REQUIRED UNDER MANDATORY PURCHASE?

YES

NO

MORTGAGEE/OTHER

NAME AND MAILING ADDRESS OF:

2ND MORTGAGEE

LOSS PAYEE

OTHER

IF OTHER, SPECIFY:

2ND

LOAN NO.:

IS INSURANCE REQUIRED UNDER MANDATORY PURCHASE?

YES

NO

COMPLETE THIS SECTION ONLY FOR PRE-FIRM BUILDINGS LOCATED IN AN SFHA.

COVERAGE

1.

HAS THE APPLICANT HAD A PRIOR NFIP POLICY FOR THIS PROPERTY?

YES

NO

2. WAS THE POLICY REQUIRED BY THE LENDER UNDER MANDATORY PURCHASE?

YES

NO

3. IF YES, HAS THE PRIOR NFIP POLICY EVER LAPSED WHILE COVERAGE WAS REQUIRED

NFIP

UNDER MANDATORY PURCHASE BY THE LENDER?

YES

NO

4.

IF YES, WAS THE LAPSE THE RESULT OF A COMMUNITY SUSPENSION?

YES

NO

PRIOR

IF YES, WHAT IS THE SUSPENSION DATE?

/

/

WHAT IS THE REINSTATEMENT DATE?

/

/

5. WILL THIS POLICY BE EFFECTIVE WITHIN 180 DAYS OF THE COMMUNITY REINSTATEMENT

AFTER SUSPENSION REFERRED TO IN (4) ABOVE?

YES

NO

N

F

I

P

C O P Y

ALL BUILDINGS

1. BUILDING PURPOSE

100% RESIDENTIAL

100% NON-RESIDENTIAL MIXED-USE — SPECIFY PERCENTAGE OF

RESIDENTIAL USE:

%

2. BUILDING OCCUPANCY

SINGLE FAMILY 2–4 FAMILY OTHER RESIDENTIAL

NON-RESIDENTIAL BUSINESS OTHER NON-RESIDENTIAL

3.IS THE BUILDING A HOUSE OF WORSHIP?

YES NO

4.IS THE BUILDING AN AGRICULTURAL

STRUCTURE? YES NO

5.BUILDING DESCRIPTION (CHECK ONE)

MAIN HOUSE

DETACHED GUEST HOUSE

DETACHED GARAGE

BARN

APARTMENT BUILDING

APARTMENT – UNIT

COOPERATIVE BUILDING

COOPERATIVE – UNIT

WAREHOUSE

TOOL/STORAGE SHED

POOLHOUSE, CLUBHOUSE, RECREATION BUILDING

OTHER:

6. CONDOMINIUM INFORMATION

IS BUILDING IN A CONDOMINIUM FORM

OF OWNERSHIP?			YES	NO
IS COVERAGE FOR THE ENTIRE BUILDING?
YES	NO
TOTAL NUMBER OF UNITS:
HIGH-RISE		LOW-RISE
IS COVERAGE FOR A CONDOMINIUM UNIT?
YES	NO

7.ADDITIONS AND EXTENSIONS (IF APPLICABLE)

DOES THE BUILDING HAVE ANY ADDITIONS

OR EXTENSIONS? YES NO (ADDITIONS AND EXTENSIONS MAY BE SEPARATELY INSURED.)

COVERAGE IS FOR:

BUILDING INCLUDING ADDITION(S) AND EXTENSION(S)

BUILDING EXCLUDING ADDITION(S) AND EXTENSION(S) PROVIDE POLICY NUMBER FOR ADDITION OR EXTENSION:

ADDITION OR EXTENSION ONLY (INCLUDE DESCRIPTION IN THE PROPERTY LOCATION BOX ABOVE). PROVIDE POLICY NUMBER FOR BUILDING EXCLUDING ADDITION(S) OR EXTENSION(S):

8.PRIMARY RESIDENCE, RENTAL PROPERTY, TENANT’S COVERAGE

IS BUILDING INSURED’S PRIMARY

RESIDENCE? YES NO IS BUILDING A RENTAL PROPERTY?

YES NO

IS THE INSURED A TENANT? YES NO IF YES, IS THE TENANT REQUESTING BUILDING

COVERAGE? YES NO

IF YES, SEE NOTICE IN SIGNATURE BLOCK ON PAGE 2.

9. BUILDING INFORMATION

IS BUILDING IN THE COURSE OF

CONSTRUCTION? YES NO IS BUILDING WALLED AND ROOFED?

YES NO

IS BUILDING OVER WATER?

NO PARTIALLY ENTIRELY

IS BUILDING LOCATED ON FEDERAL LAND?

YES

NO

IS BUILDING A SEVERE REPETITIVE LOSS

PROPERTY? YES NO

10.IS BUILDING ELEVATED? YES NO

11.BASEMENT, ENCLOSURE, CRAWLSPACE

NONE

FINISHED BASEMENT/ENCLOSURE CRAWLSPACE

UNFINISHED BASEMENT/ENCLOSURE SUBGRADE CRAWLSPACE

IS THE BASEMENT/SUBGRADE CRAWLSPACE FLOOR BELOW GRADE ON ALL SIDES?

YES NO

12.NUMBER OF FLOORS IN BUILDING (INCLUDING BASEMENT/ENCLOSED AREA, IF ANY) OR BUILDING TYPE

1

2

3 OR MORE

SPLIT LEVEL TOWNHOUSE/ROWHOUSE (RCBAP LOW-RISE ONLY)

MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER ON FOUNDATION

NON-ELEVATED BUILDINGS

1. GARAGE

IS A GARAGE ATTACHED TO THE BUILDING?

YES NO

TOTAL NET AREA OF THE GARAGE:

SQUARE FEET.

ARE THERE ANY OPENINGS (EXCLUDING DOORS) THAT ARE DESIGNED TO ALLOW THE PASSAGE OF FLOODWATERS THROUGH THE

GARAGE? YES NO

IF YES, NUMBER OF PERMANENT FLOOD OPENINGS WITHIN 1 FOOT ABOVE THE

ADJACENT GRADE: .

TOTAL AREA OF ALL PERMANENT OPENINGS: SQUARE INCHES.

IS THE GARAGE USED SOLELY FOR PARKING OF VEHICLES, BUILDING ACCESS, AND/OR

STORAGE?

YES

NO

IF YES, DOES THE GARAGE CONTAIN MACHINERY AND/OR EQUIPMENT?

YES NO

2. BASEMENT/SUBGRADE CRAWLSPACE

DOES THE BASEMENT/SUBGRADE CRAWLSPACE CONTAIN MACHINERY AND/OR

EQUIPMENT? YES NO

IF YES, SELECT THE VALUE BELOW:

UP TO $10,000

$10,001 TO $20,000

IF GREATER THAN $20,000 – INDICATE THE AMOUNT:

DOES THE BASEMENT/SUBGRADE CRAWLSPACE CONTAIN A WASHER, DRYER

OR FOOD FREEZER?

YES

NO

IF YES, SELECT THE VALUE BELOW:

UP TO $5,000

$5,001 TO $10,000

IF GREATER THAN $10,000 – INDICATE THE AMOUNT: