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ANTI-ARSON FORM http://www.nypiua.com/antiarson.

html

STATE OF NEW YORK MANDATED ANTI-ARSON APPLICATION PART1

Warning: This application must be completed and returned by the applicant or insured pursuant to section(3403) of the New York
Insurance Law and Insurance Department Regulation 96.

You may fulfill the requirement for annual submission of the New York State mandated Anti-Arson application by answering the questions
below. Before you proceed, review and complete the form you received with your renewal policy.

UNDER LAW, FAILURE TO SUBMIT MAY RESULT IN THE RESCISSION OF YOUR POLICY.

Policy Number and Suffix: -


Location Number:
Amount of Insurance:
Reason for submitting this form: New Application Change of Interest Renewal
Name of Applicant or Insured:
Location of Property:

Occupancy:

Applicant is: Owner Occupant Absentee Owner Tenant Other


If Other is selected, explain
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.

The valuation information has changed during the past year : Yes No
Purchase Information:
Date: Price: $ Cost of subsequent improvements made:$
Estimated replacement cost: $ Estimated Fair Market Value (exclusive of land): $

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For rental properties, indicate the Annual Rental Income: $


Select the valuation method used to establish the amount of insurance.

Who determined the value ?


Fax appraisal reports indicating the named insured/applicant and policy number to 212-208-9861
UNDERWRITING INFORMATION: If the answer to any of the following questions is 'Yes' , you will be prompted to respond to the
appropriate question.

1. Is the applicant other than an individual owner or sole proprietorship? Yes No


2. Are any mortgage payments (building or contents)
Yes No
overdue by 3 months or more ?
3. Are there any real estate tax liens or other tax liens against the property
Yes No
or real estate taxes overdue for one year or more ?
4. Are there any outstanding recorded violations of fire, safety, health,
Yes No
building, or construction codes at this location?
5. Has anyone with a financial interest in this property been convicted of
arson, fraud or other crime related to loss on property during the last Yes No
5 years ?
6. Is the mortgagee other than a federal or state chartered lending institution? Yes No

7. Except where federal or state chartered lending institutions are the applicants,
please answer the following question:
Have there been fire losses during the past five years exceeding $1,000 in Yes No
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,
Yes No
unoccupied or seasonal?
b) If the property is residential, are 5% or more of the apartments vacant, unoccupied
Yes No
or seasonal?
9. Is there a governmental order to vacate or destroy the building or has the building been
Yes No
classified as uninhabitable or structurally unsafe?

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10. Is the water, sewage, electricity or heat out of service? Yes No


11. OTHER POLICIES:
Yes No
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
Yes No
non-renewed in the last 3 years?
12. Has this property been under the ownership of the applicant for less than 3 years? Yes No
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 WILLFUL CONCEALMENT OR MISREPRESENTATION OF
A MATERIAL FACT OR CIRCUMSTANCES SHALL BE GROUNDS TO RESCIND THE INSURANCE POLICY.
ELECTRONIC SIGNATURE:

*** I certify that the information I have provided in this anti-arson application is true and correct. I further certify that by inputting my name and
the last four digits of my social security number in the appropriate spaces on this Web page, I validate this anti-arson application with an electronic
signature unique to me. I agree that signing this anti-arson application with my electronic signature has the same validity and effect as signing this
anti-arson application by my hand in ink. I authorize New York Property Insurance Underwriting Association to verify any information included in
this anti-arson application.

I understand and agree that by clicking the SUBMIT button on this Web page, I am transferring my anti-arson application to New York Property
Insurance Underwriting Association using the internet and I acknowledge and agree that New York Property Insurance Underwriting Association is
thus unable to guarantee the privacy and confidentiality of this electronic anti-arson application. I agree that, regardless of the type of security
features used to facilitate the submission of this electronic anti-arson application, New York Property Insurance Underwriting Association will not
be held liable for the interception, transmission failure or other misuse of this electronic anti-arson application.

If you do not agree to the terms above, you may submit this anti-arson application by mail or fax to 212-208-9861. For more information, contact
New York Property Insurance Underwriting Association at 212-208-9700.
*** PLEASE TYPE YOUR NAME:
TITLE (IF A CORPORATION):
LAST 4 DIGITS OF SOCIAL SECURITY #:

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.
PRINTING INFORMATION:

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ANTI-ARSON FORM http://www.nypiua.com/antiarson.html

The anti-arson application should be printed using your browser's print function. New York Property Insurance Underwriting Association does not
guarantee that this page can be bookmarked or saved to disk.
Use your browser's print function to print this page before you submit.

Return to Home Page

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