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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 ESTIMATED REPLACEMENT COST COST OF SUBSEQUENT IMPROVEMENTS 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 WHO DETERMINED THE VALUE UNDERWRITING INFORMATION ATTACH A COPY OF ANY APPRAISAL. IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES COMPLETE THE CORRESPONDING NUMBERED SECTION OF PART 2. IS THE APPLICANT OTHER THAN AN INDIVIDUAL OR SOLE PROPRIETORSHIP YES ARE ANY MORTAGE PAYMENTS BUILDING OR CONTENTS OVERDUE BY 3 MONTHS OR MORE ARE THERE ANY REAL ESTATE TAX LIENS OR OTHER TAX LIENS AGAINST THE PROPERTY OR REAL ESTATE TAXES OVERDUE OF ONE YR* OR MORE ARE THERE ANY OUTSTANDING RECORDED VIOLATIONS OF FIRE SAFETY HEALTH BUILDING OR CONSTRUCTION CODES AT THIS LOCATION 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 IS THE MORTGAGEE OTHER THAN A FEDERAL OR STATE CHARTERED LENDING INSTITUTION 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 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 NON-RENEWED IN THE LAST 3 YEARS c IS WATER SEWAGE ELECTRICITY OR HEAT OUT OF SERVICE a IF THE PROPERTY IS COMMERCIAL IS MORE THAN 10 OF THE RENTABLE SPACE VACANT UNOCCUPIED OR SEASONAL HAS THIS PROPERTY BEEN UNDER THE OWNERSHIP OF THE APPLICANT FOR LESS THAN 3 YEARS OTHER POLICIES 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.

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