Form Nyfa-1 - State Of New York Anti-Arson Application

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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 101.0.721 (7/82)

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