Settlement and closing
NFIP Proof of Loss Template & Example
Last updated 2026-10-10
Make the amount the policyholder requests traceable to the documents supporting it. The June 2025 NFIP Claims Manual, Section 1, “Customer Experience—Proof of Loss” (Claims Journey–56), requires a completed proof of loss and supporting documentation within 60 days of the date of loss or within an extension granted by FEMA. The policyholder signs under penalty of perjury. Completing and signing a form alone does not satisfy all SFIP requirements.
Appendix C identifies “Proof of Loss (Adjuster-Prepared), FF-206-FY-21-112” (C–7) and “Proof of Loss (Policyholder-Prepared), FF-206-FY-21-108” (C–10). The Word download here is a preparation and submission worksheet, not either official form or a signature declaration. Use the FEMA forms directory under Sources. This page addresses NFIP requirements; the library's general sworn proof of loss discusses a different policy context and its notarial practice should not be imported into this worksheet.
The Willow Bend example documents the policyholder's review, signature record and delivery of the proof of loss already identified in the NFIP final report. The preliminary report holds the initial damage assessment, and the narrative report explains the later evidence gap. Here, the task is to assemble a supported request and preserve what was actually submitted, without repeating that investigation or the settlement arithmetic.
Jurisdiction
Written primarily against US first-party property practice. Claim handling is regulated state by state — acknowledgment and response deadlines, prompt-payment requirements, adjuster licensing and unfair claims practices standards all differ — and the policy actually issued governs the claim. Where a page cites a statute, model act or regulation, confirm what applies in the state where the loss occurred. Outside the US, treat the structure as transferable and the legal references as not.
NFIP Proof of Loss template
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When to use this document
- When preparing the policyholder's supported request for payment under Section 1, “Proof of Loss,” rather than drafting another adjuster report.
- When the adjuster prepares the official proof as a courtesy and the policyholder must review its information and requested amount (Appendix C, “Proof of Loss (Adjuster-Prepared)”).
- When an additional payment requires another completed proof with support within the same time constraints (Section 2, “Requirements in Case of Loss—Multiple Proofs of Loss Allowed,” Eligibility–5).
Worked example
Fictional scenario: preparation and delivery record for the Willow Bend proof of loss, claim NF-FICTION-260901, M. Reyes, assisted by R. Calloway. All names, addresses, dates, identifiers, dollar amounts, counts and document references are fictional. No signature, official form or actual evidence is supplied. The figures are the amounts already carried into the fictional closing report; this example ends with insurer review pending.
Claim identity and submission route
Preparation record dated 29 September 2026 for M. Reyes, 214 Willow Bend, policy NF-FICTION-2048 and claim NF-FICTION-260901. R. Calloway assisted with the adjuster-prepared official proof of loss. This record indexes that separate document and is not the proof itself.
The recipient is the NFIP insurer identified in the policy record. No election to substitute a signed adjuster's report is recorded. The closing narrative will identify the completed proof and supporting schedules as separate documents. Reyes has been given the same versions being assembled for submission so the requested amount can be reviewed against a definite set of records.
Date of loss and deadline record
The loss date in the file is 1 September 2026. That date is consistent with the event account and the inspection record. The deadline check uses the date of loss, not the date of the preliminary submission or the later receipt of contractor records. No FEMA extension is relied upon in this example.
The signed proof and its supporting documents were submitted and receipt was recorded on 29 September, within the ordinary filing period. The preparation note retains both the review date and the transmission date. The pending examiner review is not used to change the recorded date of submission.
Amount requested and supporting versions
Reyes requests $20,000 for building damage and $5,000 for personal property, a total of $25,000. The supporting versions are building estimate C, personal property inventory B and the reconciliation dated 29 September. The calculation and its assumed ACV basis remain in those schedules. This index does not introduce another estimate or a second set of values.
The package also points to the inspection photographs, measured diagram and evidence supporting the damaged items. The cabinet repair-history comparison is included by reference to its indexed records. It supports the treatment of that item in estimate C; the earlier repair invoice is not a new charge added to the amount requested.
Policyholder review and signature record
On 29 September Calloway reviewed the selected proof, estimate C, inventory B and reconciliation with Reyes. Reyes checked the identifying information and the building and personal property amounts. The discussion record identifies the depreciation and deductible explanations already supplied with the schedules. No different requested amount was recorded after that review.
The fictional file records Reyes signing and swearing to the official proof on that date, under its penalty-of-perjury declaration. The completed document is retained with the reviewed schedules. No signature is reproduced here, and Calloway's preparation assistance is not recorded as execution on Reyes's behalf.
Delivery package and receipt
The insurer's claim portal receipt records delivery on 29 September of the signed proof, building estimate C, inventory B, the reconciliation and the supporting evidence index with its listed records. The receipt and the submitted documents are retained together in the claim file. The index identifies the cabinet comparison records and the flood-damage photographs separately so either can be found without searching the full narrative.
The diary records submission and receipt, not payment approval. The same proof version is the one to be identified in the closing package. No later unsigned draft has replaced the signed copy in the submission record.
Additional amounts or filing problems
No additional amount is requested in this submission, and no late-proof waiver is being relied upon. If a later request changes the amount, the current proof and its receipt will remain identifiable, with the new request linked to its own supporting revision and filing review.
At the end of this preparation record, the insurer has received the package but has not communicated its determination. The next file action is to record that response and address any identified deficiency. The $25,000 is Reyes's supported request and Calloway's corresponding recommendation; the receipt is not evidence that a check has been issued.
Section-by-section guide
What each section is for, what a good one contains, and where they typically go wrong.
1.Claim identity and submission route
Identify the claim, policyholder, insured location and recipient. Select the official adjuster-prepared or policyholder-prepared form identified in Appendix C–7 and C–10. Under Section 1, “Proof of Loss,” the insurer may instead elect to accept the adjuster's report, which the policyholder must sign. Do not assume that election merely because a closing report exists. This worksheet follows the separate proof-of-loss route.
2.Date of loss and deadline record
Record the date of loss and the applicable filing deadline together. Section 1, “Proof of Loss” (Claims Journey–56), and Section 2, “Multiple Proofs of Loss Allowed” (Eligibility–5), use 60 days from the loss, subject to a FEMA extension. An adjuster's offer to help is a courtesy, not an extension. Keep any applicable FEMA extension and its scope in the file; a planned submission date is only a work target.
3.Amount requested and supporting versions
Identify the building and personal property amounts requested and the exact schedules supporting them. Section 2, “Requirements in Case of Loss—Proof of Loss” (Eligibility–5), requires support for both direct physical loss by or from flood and the amount requested. Section 1, “Examination—NFIP Insurer Notes—Proof of Loss” (Claims Journey–71), calls for review of accuracy, support and matching values. Link to the estimate and inventory revisions rather than relying on an unexplained total.
4.Policyholder review and signature record
Appendix C, “Proof of Loss (Adjuster-Prepared),” directs the policyholder to review the information and requested amount. Section 2, “Proof of Loss,” says only the policyholder, or the executor for a deceased policyholder, can sign. “Signed and Sworn” (Eligibility–5) supports electronic signatures under insurer practices and applicable law, with signer intent, association with the document, authentication and preserved document integrity. Record execution of the actual proof; this worksheet supplies no substitute attestation or notary block.
5.Delivery package and receipt
Section 1, “Proof of Loss,” requires submission to the NFIP insurer with support. Use a package index and receipt record to show the document and attachments delivered. Section 1, “Examination—Proof of Loss,” describes the insurer's accuracy and sufficiency review. Receipt should therefore be recorded separately from a decision accepting the request. The claim diary can retain the transmission history.
6.Additional amounts or filing problems
Section 2, “Multiple Proofs of Loss Allowed,” keeps additional supported proofs within the same time constraints. Section 1, “Examination—Proof of Loss,” requires a new proof if the amount to be paid exceeds the amount on the proof. Under “Overdue Proof of Loss” (Claims Journey–65), an insurer receiving a signed proof after the deadline must request a waiver through Pivot and obtain FEMA approval before payment. Record the actual status; neither an additional request nor a waiver request establishes its own approval.
Common mistakes
The failure modes that show up most often when this document is reviewed later.
Starting the proof deadline when the adjuster delivers an estimate.
“Proof of Loss” (Claims Journey–56) starts the 60-day period at the date of loss, subject to a FEMA extension. A reporting or estimating milestone does not supply a new trigger.
Submitting only a signed form or this companion worksheet.
“Proof of Loss” (Claims Journey–56 and Eligibility–5) requires supporting documentation as well as execution. This worksheet does not contain the official proof or its declaration.
Having the assisting adjuster sign for the policyholder.
Section 2, “Proof of Loss” (Eligibility–5), identifies the policyholder, or executor for a deceased policyholder, as the signer. Appendix C–7 treats adjuster preparation as a courtesy followed by policyholder review.
Treating a supplemental proof as a fresh filing period.
“Multiple Proofs of Loss Allowed” (Eligibility–5) expressly keeps additional completed proofs and support within the same time constraints.
Recording a late-proof waiver request as approval to pay.
“Overdue Proof of Loss” (Claims Journey–65) requires the insurer to receive FEMA's waiver approval before issuing payment when the signed proof arrives after the deadline.
Questions
- Which official proof-of-loss forms does this edition identify?
- Appendix C names the adjuster-prepared proof, FF-206-FY-21-112 (C–7), and the policyholder-prepared proof, FF-206-FY-21-108 (C–10). Obtain the official document through the FEMA forms directory under Sources. The Word download on this page is a companion worksheet.
- Does the policyholder have to use the adjuster's help?
- No. Section 1, “Proof of Loss” (Claims Journey–56), says the policyholder may complete the proof without the independent adjuster's assistance. Assistance does not remove the requirements for a timely, supported and signed submission.
- Can the proof be signed electronically?
- Section 2, “Signed and Sworn” (Eligibility–5), encourages electronic signatures and describes acceptance under insurer practices and applicable law. It also specifies intent to sign, association with the document, signer identification and authentication, and preservation of the signed document's integrity. Use the insurer's accepted process for the actual proof.
- What if the amount to be paid increases?
- Section 1, “Examination—NFIP Insurer Notes—Proof of Loss” (Claims Journey–71), says the examiner must secure a new proof matching the revised amount if payment exceeds the amount on the proof. Additional proofs still require support within the time constraints in “Multiple Proofs of Loss Allowed” (Eligibility–5).
The blank template
Exactly what is in the Word download, so you can see the structure before deciding whether you want it.
Claim identity and submission route
Date of loss and deadline record
Amount requested and supporting versions
Policyholder review and signature record
Delivery package and receipt
Additional amounts or filing problems
Download this template
Free Word download, no email required. Or open it in Professional Drafter — it lands in your template library, ready to draft against.
Sources
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This page is a documentation aid, not legal advice and not a coverage opinion. Claim-handling requirements vary by state and by policy wording, and a template cannot tell you what your file requires. The worked example describes a fictional loss.