U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program
FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM
IMPORTANT – PLEASE PRINT OR TYPE; ENTER DATES AS MM/DD/YYYY.
O.M.B. No. 1660-0006 Expires April 30, 2020
POLICY #:
POLICY
PERIOD
POLICY PERIOD IS FROM
/ /
TO
/ /
CANCELLATION EFFECTIVE DATE:
/ /
AGENT/PRODUCER
INFORMATION
NAME AND MAILING ADDRESS OF AGENT/PRODUCER ON THE POLICY BEING CANCELED.
AGENCY NO.: AGENT’S TAX ID:
PHONE NO.: FAX NO.:
EMAIL ADDRESS:
INSURED INFORMATION
NAME AND MAILING ADDRESS OF INSURED FOR MAILING REFUND:
PHONE NO.:
1ST
MORTGAGEE
NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:
LOAN NO.:
2ND MORTGAGEE /
OTHER
NAME AND MAILING ADDRESS OF OTHER PARTIES NOTIFIED:
PROPERTY LOCATION
INSURED PROPERTY LOCATION:
CANCELLATION REASON CODES
CANCELLATION REASON CODE:
1.
BUILDING SOLD OR REMOVED, DESTROYED OR PHYSICALLY ALTERED
T
O N
O L
O
N
G
E
R M
E
E
T T
H
E D
E
F
I
N
I
T
I
O
N O
F A
N E
L
I
G
I
B
L
E B
U
I
LDING
2. CONTENTS SOLD OR REMOVED
3. POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON
EXPIRATION DATE WITH OTHER INSURANCE COVERAGE
4. DUPLICATE NFIP POLICIES
5. NON-PAYMENT
6. RISK NOT ELIGIBLE FOR COVERAGE
7. PROPERT Y CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)
8. POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED
BY MORTGAGEE AS PROPERTY NOT IN SFHA
9. INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION
10. CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP
12. MORTGAGE PAID OFF
13. VOIDANCE PRIOR TO EFFECTIVE DATE
15. INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)
18. MORTGAGE PAID OFF ON AN MPPP POLICY
19. INSURANCE NO LONGER REQUIRED BY THE MORTGAGEE BECAUSE THE
BUILDING HAS BEEN REMOVED FROM THE SFHA BY MEANS OF A LOMA
20. POLICY WRITTEN TO WRONG FACILITY (SEVERE REP
ETITIVE LOSS PROPERTY)
21. OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES
22. CANCEL/REWRITE DUE TO MISRATING
23. FRAUD (FEMA APPROVAL REQUIRED)
24. CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR
25. CANCEL/REWRITE TO PROCESS HFIAA REFUND
REFUND
MAKE REFUND PAYABLE TO (CHECK ONE): INSURED PAYOR AGENT (REASON 5 ABOVE ONLY)
MAIL REFUND TO (CHECK ONE): INSURED PAYOR AGENT (REASON 5 ABOVE OR AT REQUEST OF INSURED)
SIGNATURE
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. SEE REVERSE SIDE OF COPIES 2, 3, AND 4.
/ /
SI GN AT UR E OF IN SUR ED
(NOT REQUIRED FOR REASON 5, 6, 22, OR 25)
DATE (MM / D D / YYYY)
/ /
SIGNATURE OF OTHER INSURED DAT E (M M / DD / Y YYY )
/ /
SI GN AT UR E OF AGE N T/PR ODU C ER DAT E (M M / DD / Y YYY )
FEMA Form 086-0-2 Previously FEMA Form 81-17 F-052 (JUN 2015)
PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT/PRODUCER: SEND ORIGINAL TO NFIP, KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO THE INSURED, AND FOURTH COPY TO MORTGAGEE.
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