Form 086-0-19 Increased Cost of Compliance (ICC) Adjuster Report

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB Control Number: 1660-0005
Expiration: MM DD, YYYY

INCREASED COST OF COMPLIANCE (ICC) ADJUSTERS REPORT
2. NAME OF INSURER

1. NAME OF INSURED
3. PROPERTY ADDRESS (Include city, state, and zip code)
4. COMMUNITY NAME/NUMBER

5. FLOOD ZONE

6. POLICY NUMBER

7. POLICY TERM

8. BUILDING POLICY LIMIT

9. DATE OF LOSS

10. OCCUPANCE TYPE
12. ADJUSTERS FILE NO.

11. ADJUSTING COMPANY

13. Has the Insured received a determination from the community official that the structure must be brought into compliance with the local
floodplain management ordinance?
Yes
No
Date of Declaration
14. Local Official's Name:

15. Telephone Number

16. Under the flood loss meet the NFIP/ICC 50% substantial damage or average 25% repetitive loss requirements?
Yes

DRAFT

No

17. Under which provision is the ICC claim based?

Demolition

Substantial Damage

Repetitive Loss

Elevation

Floodproofing

Demolition/Elevation or Floodproofing

Mitigation option(s):

Relocation

Relocation/Elevation or Floodproofing

18. If relocation, indicate the following:
New Address:

New flood risk zone:

19. Current validation of structure as determined by the community official $
20. Basis of validation:
21. Full cost of compliance not limited to the amount of ICC coverage

$

22. Amount paid under the ICC Coverage D (excluding salvage and subrogation)

$

If repetitive loss, indicate the following (paid flood building claims only):
Date of Prior Claim
Insurer
Policy Number
within 10 yrs.

Building Payment

RCV Damages
(whole dollars)

ACV Damages
(whole dollars)

23. If repetitive loss, the valuation of the structure as determined by the community official near the date of the prior loss:
$
Date of valuation:
24. Basis of valuation:
25. Date of Report

26. ADJUSTER'S SIGNATURE

27. ADJUSTER'S FCN

See Page 2 for Privacy Act Statement and Paperwork Burden Disclosure Notice
FEMA FORM 000-0-0 (05/15)

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PRIVACY ACT STATEMENT
The information requested is necessary to process the subject loss. The authority to collect the information is 42 U.S.C. §§ 4001 to 4130. It is
voluntary on your part to furnish the information. However, omission of an item may preclude processing of the form. The Federal Emergency
Management Agency will not disclose this information, except to: the servicing agent acting as the Federal 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 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 6
hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and submitting these forms. 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 these forms. Send comments
regarding the accuracy of the burden estimate and suggestions for reducing the burden to: Information Collections Management, 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.

TITLE

BURDEN HOURS

086-0-06

Worksheet-Contents-Personal Property

2.50 Hours

086-0-07

Worksheet-Building

2.50 Hours

086-0-08

Worksheet-Building (Continued)

1.00 Hours

Proof of Loss

.08 Hours

Increased Cost of Compliance

2.00 Hours

Notice of Loss

.07 Hours

086-0-12

Statement as to Full Cost to Repair or Replacement Cost Coverage,
Subject to the Terms and Conditions of this Policy

.10 Hours

086-0-13

Adjuster's Preliminary Report

.07 Hours

086-0-14

Adjuster's Final Report

.07 Hours

086-0-15

National Flood Insurance Program Narrative Report

.08 Hours

086-0-16

Cause of Loss and Subrogation Report

1.00 Hours

086-0-17

Manufactured (Mobile) Home/Travel Trailer Worksheet

.50 Hours

086-0-18

Mobile Home/Travel Trailer Worksheet (Continued)

.25 Hours

086-0-19

Increased Cost of Compliance (ICC) Adjuster Report

.42 Hours

086-0-20

Adjuster's Preliminary Flood Damage Assessment

.25 Hours

086-0-21

Adjuster's Certification Application

.25 Hours

086-0-09
086-0-10
086-0-11

FEMA FORM 000-0-0 (05/15)

DRAFT

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