Form Nyfa-1 - State Of New York Anti-Arson Application Page 2
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1
2STATE 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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