NATIONAL FLOOD INSURANCE PROGRAM

DEPARTMENT OF HOMELAND SECURITYFEDERAL EMERGENCY MANAGEMENT AGENCYADJUSTER CERTIFICATION APPLICATION

O.M.B. No. 1660-0005Expires September 30, 2010

Privacy Act Statement

The information requested is necessary to process the subject loss. The authority to collect the information is Title 42, U.S. Code, Section 4001 to 4028. It isvoluntary on your part to furnish the information. However, omission of an item may preclude processing of the form. The information will not be disclosed outsideof the Federal Emergency Management Agency, except to the servicing agent, acting as the government's fiscal agent; to claims adjusters to enable them to confirmcoverage and the location of insured property; to certain Federal, State, and Local Government agencies for determining eligibility for benefits and for verification ofnonduplication of benefits; to the Department of Justice for purposes of litigation or as required by law; and to State and Local agencies for acquisition andrelocation-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 and/or application. 

Paperwork Burden Disclosure Notice 

Public reporting burden for this form is estimated to average 15 minutes per response. The burden estimate includes the time, effort or financial resources expendedby persons to generate, maintain, retain, disclose, or provide information to the Mitigation Division or its agent. You are not required to respond to this collection ofinformation unless a currently valid OMB control number and expiration date is displayed in the upper right corner of the these forms. Send comments regarding theaccuracy of the burden estimate and suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, FederalEmergency Management Agency, 500 C Street, S.W., Washington, DC 20472, Paperwork Reduction Project (1660-0005). NOTE: Do not send your completedform to this address.

Recertification


(Recertification: 1) Unchecked
No


(No: 1) Unchecked
Staff Adjuster


(Staff Adjuster: 1) Unchecked
Yes


(Yes: 1) Unchecked
New Certification


(New Certification: 1) Unchecked
Please complete Section I below in its entirety. Then turn the form over and complete all applicable parts in Section II. Sign and date theform and mail it to: NFIP Bureau & Statistical Agent, Certification Coordinator, P.O. Box 310, Lanham, MD 20703-0310.

SECTION I - PLEASE PRINT

1. NAME


(1. NAME) 
2. FLOOD CERTIFICATION NUMBER (FSN)


(2. FLOOD CERTIFICATION NUMBER (FSN)) 
3. STREET ADDRESS (include city, state, and zip code)


(3. STREET ADDRESS (include city, state, and zip code)) 
a. DAYTIME PHONE NO.


(a. DAYTIME PHONE NO.) 
b. EVENING PHONE NO.


(b. EVENING PHONE NO.) 
c. E-MAIL ADDRESS


(c. E-MAIL ADDRESS) 
d. FAX NO.


(d. FAX NO.) 
If yes, which state(s)?


(If yes, which state(s)?) 
4. Are you a licensed adjuster?

Yes


(Yes: 1) Unchecked
No


(No: 1) Unchecked
5. Number of years of flood adjuster experience


(5. Number of years of flood adjuster experience) 
Number of years of property adjuster experience


(Number of years of property adjuster experience) 
6. Has your license ever been revoked?

Yes


(Yes: 1) Unchecked
No


(No: 1) Unchecked
If yes, reason:


(If yes, reason:) 
7. Have you ever been suspended or terminated by the NFIP?

Yes


(Yes: 1) Unchecked
No


(No: 1) Unchecked
If yes, reason:


(If yes, reason:) 
8. Have you ever attended an NFIP Claims Presentation?

Yes


(Yes: 1) Unchecked
No


(No: 1) Unchecked
If yes, location:


(If yes, location:) 
9. Did you attend a company sponsored training session?

Yes


(Yes: 1) Unchecked
No


(No: 1) Unchecked
Company:


(Company:) 
Date Attended:


(Date Attended:) 
If yes, location:


(If yes, location:) 
10. Present Errors and Omissions Carrier:


(10. Present Errors and Omissions Carrier:) 
SECTION II - PLEASE PRINT

Check "Yes" or "No" to indicate the category(s) in which you are seeking certification:

11. Residential (Dwelling)

Yes


(Yes: 1) Unchecked
No


(No: 1) Unchecked
12. Manufactured (Mobile) Home/Travel Trailer

No


(No: 1) Unchecked
Yes


(Yes: 1) Unchecked
Commercial (General Property)

13. Small Commercial (up to $100,00)

No


(No: 1) Unchecked
Yes


(Yes: 1) Unchecked
14. Large Commercial (from $100,001 to $500,000)

No


(No: 1) Unchecked
Yes


(Yes: 1) Unchecked
15. Condominium (RCBAP)

No


(No: 1) Unchecked
Yes


(Yes: 1) Unchecked
FEMA Form 81-110, OCT 07REPLACES ALL PREVIOUS EDITION.F-673


SECTION II - (continued)

For the category(ies) that you have selected, answer the following questions:

* What is the building dollar limit estimate that you have prepared in this category?


(* What is the building dollar limit estimate that you have prepared in this category?) 
* What is the dollar limit on contents inventory that you have prepared?


(* What is the dollar limit on contents inventory that you have prepared?) 
* What is the largest combined loss and claim that you have adjusted?

Total Amount $


(Total Amount $) 
Building $


(Building $) 
Contents $


(Contents $) 
If you have adjusted a condominium loss, provide the name, date of loss, location (complete address), and contact individual, along withtelephone number.


(If you have adjusted a condominium loss, provide the name, date of loss, location (complete address), and contact individual, along with telephone number.) 
If you are applying for Large Commercial or RCABAP authorization, provide the names of three insurance company claims personnel who can becontacted to reference your adjusting experience and professionalism.

NAME


(NAME) 
COMPANY


(COMPANY) 
DATE


(DATE) 
NAME


(NAME) 
COMPANY


(COMPANY) 
DATE


(DATE) 
NAME


(NAME) 
COMPANY


(COMPANY) 
DATE


(DATE) 
DECLARATION ACKNOWLEDGEMENT.
I declare that I have read the current Standard Flood Insurance policies (the Dwelling Form, the General Property Form, and the ResidentialCondominium Building Association Policy) and that all responses on this applicaton are true and accurate.
I acknowledge that misrepresentation of any information provided on this application is grounds for denial of certification, or for suspension ortermination of certification if misrepresentation is discovered after certification has been granted.

Signature


(Signature) 
Date


(Date) 

Privacy Act StatementThe information requested is necessary to process the subject loss. The authority to collect the information is Title 42, U.S. Code, Section 4001 to4028. It is voluntary on your part to furnish the information. However, omission of an item may preclude processing of the form. The informationwill not be disclosed outside of the Federal Emergency Management Agency, except to the servicing agent, acting as the 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 Governmentagencies for determining eligibility for benefits and for verification of agencies for acquisition and relocation-related projects, consistent with theNational Flood Insurance Program and consistent with the routine uses described in the program's system of record. Failure by you to provide someor all of the information may result in delay in processing or denial of this claim and/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 hoursper response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the dataneeded, and completing and submitting these forms. You are not required to respond to this collection of information unless a currently valid OMBcontrol number and expiration date is displayed in the upper right corner of the these forms. Send comments regarding the accuracy of the burdenestimate and suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal EmergencyManagement Agency, 500 C Street, S.W., Washington, DC 20472, Paperwork Reduction Project (1660-0005). NOTE: Do not send yourcompleted form to this address.

FEMA Form No.  Title  Burden Hours

81-40 Worksheet-Contents-Personal Property 2.5 Hours81-41 Worksheet-Building 2.5 Hours81-41A Worksheet-Building (Cont'd) 1.0 Hours81-42 Proof of Loss .08 Hours81-42A Increased Cost of Compliance 2.0 Hours81-43 Notice of Loss .07 Hours81-44 Statement as to Full Cost to Repair or Replacement .10 HoursCost Coverage, Subject to the Terms and Conditionsof this Policy81-57 National Flood Insurance Program Preliminary Report .07 Hours81-58 National Flood Insurance Program Final Report .07 Hours81-59 National Flood Insurance Program Narrative Report .08 Hours81-63 Cause of Loss and Subrogation Report 1 Hour81-96 Manufactured (Mobile) Home/Travel Trailer Worksheet .50 Hours81-96AMobile Home/Travel Trailer Worksheet (Continued).25 Hours81-98 Increased Cost of Compliance (ICC) Adjuster Report .42 Hours81-109Adjuster Preliminary Damage Assessment.25 Hours81-110Adjuster Certification Application.25 Hours