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STATE OF NEW YORK ANTI-ARSON ... - Brownstone …

STATE OF NEW YORK ANTI-ARSON APPLICATION (NYFA-1) PART 1 WARNING: This application must be completed and returned by the applicant or insured pursuant

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Text of STATE OF NEW YORK ANTI-ARSON ... - Brownstone …

STATE OF NEW YORK ANTI-ARSON APPLICATION (NYFA-1) PART 1 WARNING: This application must be completed and returned by the applicant or insured pursuant to Section 168-j of the New York Insurance Law and Insurance Department Regulation 96 NAME OF APPLICANT OR INSURED LOCATION OF PROPERTY AMOUNT OF INSURANCE $ APPLICANT IS: [ ] OWNER OCCUPANCY [ ] ABSENTEE OWNER [ ] TENANT [ ] OTHER OCCUPANCY (S) VALUATION: THIS INFORMATION HELPS TO EXPLAIN THE AMOUNT OF INSURANCE SELECTED AT THE TIME OF APPLICATION, BUT DOES NOT DETERMINE THE VALUE AT THE TIME OF LOSS. PURCHASE INFORMATION: DATE PRICE $ COST OF SUBSEQUENT IMPROVEMENTS $ ESTIMATED REPLACEMENT COST $ ESTIMATED FAIR MARKET VALUE (exclusive of land) $ FOR RENTAL PROPERTIES, INDICATE THE ANNUAL RENTAL INCOME $ CHECK THE VALUATION METHOD USED TO ESTABLISH THE AMOUNT OF INSURANCE: [ ] REPLACEMENT COST [ ] REPLACEMENT COST LESS PHYSICAL DEPRECIATION [ ] FAIR MARKET VALUE (EXCLUSIVE OF LAND) [ ] OTHER WHO DETERMINED THE VALUE? ATTACH A COPY OF ANY APPRAISAL. UNDERWRITING INFORMATION: IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES , COMPLETE THE CORRESPONDING NUMBERED SECTION OF PART 2. YES NO 1. IS THE APPLICANT OTHER THAN AN INDIVIDUAL OR SOLE PROPRIETORSHIP? ____ ____ 2. ARE ANY MORTAGE PAYMENTS (BUILDING OR CONTENTS) OVERDUE BY 3 MONTHS OR MORE? ____ ____ 3. ARE THERE ANY REAL ESTATE TAX LIENS OR OTHER TAX LIENS AGAINST THE PROPERTY OR REAL ESTATE TAXES OVERDUE OF ONE YR. OR MORE? ____ ____ 4. ARE THERE ANY OUTSTANDING RECORDED VIOLATIONS OF FIRE, SAFETY, HEALTH, BUILDING OR CONSTRUCTION CODES AT THIS LOCATION? ____ ____ 5. HAS ANYONE WITH A FINANCIAL INTEREST IN THIS PROPERTY BEEN CONVICTED OF ARSON, FRAUD OR OTHER CRIMES RELATED TO LOSS ON PROPERTY DURING THE LAST 5 YEARS? ____ ____ 6. IS THE MORTGAGEE OTHER THAN A FEDERAL OR STATE CHARTERED LENDING INSTITUTION? ____ ____ 7. EXCEPT WHERE FEDERAL OR STATE CHARTERED LENDING INSTITUTIONS ARE THE APPLICANTS, PLEASE FURNISH THE FOLLOWING INFORMATION: ____ ____ HAVE THERE BEEN FIRE LOSSES DURING THE PAST FIVE YEARS EXCEEDING $1,000 IN DAMAGES TO THIS PROPERTY OR TO ANY PROPERTY IN WHICH THE APPLICANT HAS AN EQUITY INTEREST AS AN OWNER OR MORTGAGEE? ____ ____ 8. (a) IF THE PROPERTY IS COMMERCIAL, IS MORE THAN 10% OF THE RENTABLE SPACE VACANT, UNOCCUPIED OR SEASONAL? ____ ____ (b) IF THE PROPERTY IS RESIDENTIAL, ARE 5% OR MORE OF THE APARTMENTS VACANT, UNOCCUPIED OR SEASONAL? ____ ____ (c) IS WATER, SEWAGE, ELECTRICITY OR HEAT OUT OF SERVICE? ____ ____ 9. OTHER POLICIES: (a) IS THERE ANY OTHER INSURANCE IN FORCE OR APPLIED FOR ON THIS PROPERTY? ____ ____ (b) HAS ANY COVERAGE OR POLICY ON THIS PROPERTY BEEN DECLINED, CANCELLED OR NON-RENEWED IN THE LAST 3 YEARS? ____ ____ 10. HAS THIS PROPERTY BEEN UNDER THE OWNERSHIP OF THE APPLICANT FOR LESS THAN 3 YEARS? ____ ____ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT OR CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. THE PROPOSED INSURED AFFIRMS THAT THE FOREGOING INFORMATION IS TRUE AND AGREES THAT THESE APPLICATIONS SHALL CONSTITUTE A PART OF ANY POLICY ISSUED WHETHER ATTACHED OR NOT AND THAT ANY WILLFUL CONCEALMENT OR MISREPRESENTATION OF A MATERIAL FACT OR CIRCUMSTANCES SHALL BE GROUNDS TO RECIND THE INSURANCE POLICY. SIGNATURE OF PROPOSED INSURED TITLE DATE ________________________________________ _______ ______________________________ ___________________________ INSUREDS SHALL NOTIFY THE INSURER IN WRITING OF ANY CHANGE IN THE INFORMATION CONTAINED HEREIN, UPON RENEWAL OR ANNUALLY, WHICHEVER IS SOONER. FAILURE TO COMPLY MAY RESULT IN RESCISSION OF YOUR POLICY. FM (7/82) STATE OF NEW YORK ANTI-ARSON APPLICATION (NYFA-1) PART 2 OWNERSHIP INFORMATION: 1. LIST THE NAMES AND ADDRESS OF: SHAREHOLDERS OF A CORPORATION PARTNERS, INCLUDING LIMITED PARTNERS TRUSTEES AND BENEFICIARIES NOTE: LIST ONLY THOSE POSSESSING AN OWNERSHIP INTEREST OF 25% OR MORE, EXCEPT FOR CLOSE CORPORATION BENEFICIARIES WHERE ALL OWNERS SHOULD BE LISTED. NAME ADDRESS POSITION INTEREST % 2. MORTGAGE PAYMENTS MORTGAGE _______________________________ DATE DUE_______________________AMOUNT DUE ____________________________ LIST ANY OTHER ENCUMBRANCES: 3. UNPAID TAXES OR UNPAID LIENS: TYPE _________________________ DATE DUE_______________________AMOUNT DUE ____________________________ 4. CODE VIOLATIONS: DATE _______________________________________ DESCRIBE ________________________________________ ________________________ 5. CONVICTIONS: DATE ________________________________________ ____ DESCRIBE ________________________________________ ________________________ ________________________________________ _________________________ NAME OF PERSON ________________________________________ _________________ 6. NAME(S) OF UNCHARTERED MORTGAGEES: 7. LOSSES: LOCATION _________________________________ DATE _____________ AMOUNT ____________ DESCRIPTION _______________________ ________________________________________ _______________ _____________________ _______________________ ______________________________________ ________________________________________ _______________ _____________________ _______________________ ______________________________________ ________________________________________ _______________ _____________________ _______________________ ______________________________________ 8. VACANCY AND/OR UNOCCUPANCY: INDICATE SEASONAL PERIOD (IF ANY) WHEN BUILDING IS UNUSED: FOR APARTMENT BUILDINGS, INDICATE: TOTAL UNITS __________________________ UNOCCUPIED UNITS ________________________________________ _ FOR OTHER BUILDINGS INDICATE: VACANCY ___________________________________ % UNOCCUPANCY ________________________________________ ____ FOR ALL BUILDINGS INDICATE THE FOLLOWING: REASON FOR VACANCY/UNOCCUPANCY: ANTICIPATED DATE OF OCCUPANCY: IF THE BUILDING IS VACANT OR UNOCCUPIED, INDICATE HOW IT IS PROTECTED FROM UNAUTHORIZED ENTRY YES NO IS THERE A GOVERNMENTAL ORDER TO VACATE OR DESTROY THE BUILDING OR HAS THE BUILDING BEEN CLASSIFIED AS UNINHABITABLE OR STRUCTURALLY UNSAFE? _____ _____ IF WATER, SEWAGE, ELECTRICITY OR HEAT IS OUT OF SERVICE, EXPLAIN CIRCUMSTANCES: ________________________________________ __ IS THERE UNREPAIRED DAMAGE OR HAVE ITEMS BEEN STRIPPED FROM THE BUILDING? IF YES, DESCRIBE: ___________________________ _____ _____ IS THE BUILDING FOR SALE? IF YES, DATE PUT UP FOR SALE: ____________________________ _____ _____ 9. OTHER POLICIES: INDICATE STATUS: (IN FORCE, APPLIED FOR, DECLINED, CANCELLED OR NONRENEWED) STATUS DATE AMOUNT OF INSURANCE CARRIER POLICY# ________________________________________ ________________________________________ __________________ ________________________________________ __________________________ ________________ _______________________________________ ______________________ ___________________________________ ________________________________________ __________________________ ________________ _______________________________________ ______________________ ___________________________________ ________________________________________ __________________________ ________________ 10. LIST ALL REAL ESTATE TRANSACTIONS DURING THE LAST 3 YEARS INVOLVING THIS PROPERTY. DATE SELLING PRICE NAME OF SELLER AMOUNT OF MORTGAGE MORTGAGEE __________________________ _________________________________ ________________________________________ _______ ________________________________________ ________________________________ __________________________ _________________________________ ________________________________________ _______ ________________________________________ ________________________________ ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT OR CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. THE PROPOSED INSURED AFFIRMS THAT THE FOREGOING INFORMATION IS TRUE AND AGREES THAT THESE APPLICATIONS SHALL CONSTITUTE A PART OF ANY POLICY ISSUED WHETHER ATTACHED OR NOT AND THAT ANY WILLFUL CONCEALMENT OR MISREPRESENTATION OF A MATERIAL FACT OR CIRCUMSTANCES SHALL BE GROUNDS TO RECIND THE INSURANCE POLICY. SIGNATURE OF PROPOSED INSURED TITLE DATE ________________________________________ _______ ______________________________ ___________________________

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