U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program
O.M.B. No. 1660-0006 Expires November 30, 2016
FLOOD INSURANCE APPLICATION, PART 2 (OF 2)
ALL DATA PROVIDED BY THE INSURED OR OBTAINED FROM THE ELEVATION
CERTIFICATE SHOULD BE REVIEWED AND TRANSCRIBED BELOW. THIS PART OF
THE APPLICATION MUST BE COMPLETED FOR ALL BUILDINGS.
NEW RENEWAL TRANSFER (NFIP ONLY)
PRIOR POLICY #:
SECTION I – ALL BUILDING TYPES
1. Building Use:
Main house/building
Agricultural building
Poolhouse, clubhouse, recreation building
Other:
Detached guest house
Warehouse
Detached garage
Tool/storage shed
2. Garage
a) Is there a garage attached to or part of the building?
YES NO
If the answer to 2a is YES, answer 2b through 2f.
b) Total area of the garage: square feet.
c) 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.
d) Is the garage used solely for parking of vehicles, building
access, and/or storage? YES NO
e) Does the garage contain machinery and/or equipment? YES NO
If yes, check the applicable items:
Furnace Heat pump Air conditioner
Water heater Fuel tank Cistern
Elevator equipment Washer & dryer Food freezer
Other machinery and/or equipment servicing the building (describe):
f) Does the garage have more than 20 linear feet of finished interior wall,
paneling, etc.? YES
NO
3. Basement/Subgrade Crawlspace
a) Is the basement/subgrade crawlspace floor below grade on all sides?
YES NO
b) If yes, does the basement/subgrade crawlspace contain machinery and/or
equipment? YES NO
If yes, check the applicable items:
Furnace Heat pump Air conditioner
Water heater Fuel tank Cistern
Elevator equipment Washer & dryer Food freezer
Other machinery and/or equipment servicing the building (describe):
4. Additions and Extensions (if Applicable)
Coverage is for:
Building including addition(s) and extension(s)
Bu ilding excluding addition(s) and extension(s)
Provide policy number for addition or extension:
Addition or extension only (include description in the Property Location
box in Part 1)
Provide policy number for building excluding addition(s) or extension(s):
SECTION II – ELEVATED BUILDINGS
(Including Manufactured [Mobile] Homes/Travel Trailers)
1. Elevating Foundation Type
Piers, posts, or piles
Reinforced masonry piers or concrete piers or columns
Reinforced concrete shear walls
S olid foundation walls (Note: Not approved for elevating in
Zones V1–V30, VE, or V.)
2. Machinery and Equipment Below the Elevated Floor
Does the area below the elevated floor contain machinery
and/or equipment? YES NO
If yes, check the applicable items:
Furnace Heat pump Air conditioner
Water heater Fuel tank Cistern
Elevator equipment Washer & dryer Food freezer
Other machinery and/or equipment servicing the building (describe):
3. Area Below the Elevated Floor
a) Is the area below the elevated floor enclosed? YES NO
If yes, check one of the following: Fully Partially
b) Does the area below the elevated floor contain elevators?
YES NO If yes, how many?
If the answer to 3a or 3b is YES, answer 3c through 4b.
c) Indicate material used for enclosure:
Insect screening
Light wood lattice
Solid wood frame walls (if breakaway, submit cer
tification documentation)
Solid wood frame walls (non-breakaway)
Masonry walls (if breaka
way, submit certification documentation)
Masonry walls (non-breakaway)
Other (describe):
d) If enclosed with a material other than insect screening or light wood
lattice, provide size of enclosed area: square feet.
e) Is the enclosed area used for any purpose other than solely for parking
vehicles, building access, and/or storage? YES NO
If yes, describe:
f) Does the enclosed area have more than 20 linear feet of
finished interior wall, paneling, etc.?
YES NO
4. Flood Openings
a) Is the enclosed area/crawlspace constructed with openings
(excluding doors) to allow the passage of floodwaters through the
enclosed area? YES
NO
If yes, indicate number of permanent flood openings within 1 foot
above adjacent grade:
.
T
otal area of all permanent flood openings:
square inches.
b) Are flood openings engineered?
YE
S NO If yes, submit certification.
SECTION III – MANUFACTURED (MOBILE) HOMES/TRAVEL TRAILERS
(Wheels must be removed for travel trailer to be insurable.)
1. Manufactured (Mobile) Home/Travel Trailer Data
Year of manufacture:
Make:
Model number:
Serial number:
Dimensions: ×
feet
Are there any permanent additions and/or extensions?
YES NO
If yes, the dimensions are:
× feet
2. Anchoring
The manufactured (mobile) home/travel trailer anchoring
system utilizes: (Check all that apply.)
Over-the-top ties
Ground anchors
Frame ties Slab anchors
Frame connectors Other (describe):
3. Installation
The manufactured (mobile) home/travel trailer was installed in
accordance with: (Check all that apply.)
Manufacturer’s specifications
Local floodplain management standards
State and/or local building standards
THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE
BY FINE AND/OR IMPRISONMENT UNDER APPLICABLE FEDERAL LAW.
/ /
SIGNATURE OF INSURANCE AGENT/PRODUCER DATE (MM/DD/YYYY)
/ /
SIGNATURE OF INSURED (OPTIONAL) DATE (MM/DD/YYYY)
of
FEMA Form 086-0-1
Previously FEMA Form 81-16
F-050 (DEC 2013)
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signature
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