Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 08 - PROPERTY AND CASUALTY INSURANCE
Chapter 31.08.01 - Antiarson Application
Section 31.08.01.03 - Standard Antiarson Application-Part 1
Current through Register Vol. 51, No. 6, March 22, 2024
NAME OF APPLICANT/INSURED ______________________________________
LOCATION OF STRUCTURE __________________________________________
PRESENT OCCUPANCY OF STRUCTURE _________________________________
Amount of Insurance __________ Applicant is:
Owner Occupant [ ] Absentee Owner [ ] Tenant [ ]
A. 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.
Cost of Subsequent Improvements $________________________
Estimated Fair Market Value (exclusive of land) $_______
$_____________________________________________________________
Replacement Cost______________________________________ Replacement Cost Less Physical Depreciation___________ Fair Market Value (exclusive of land)_________________ Other (Describe)______________________________________
Attach a copy of any appraisal.
B. UNDERWRITING INFORMATION: If the answer to any of the following is "yes", complete Part 2.
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
THE PROPOSED INSURED DECLARES THAT THE INFORMATION PROVIDED ON THIS AND ANY OTHER APPLICATION, IS TRUE, COMPLETE, AND CORRECT BASED ON HIS/HER RECORDS, KNOWLEDGE AND BELIEF. THE PROPOSED INSURED AGREES THAT THESE APPLICATIONS SHALL CONSTITUTE A PART OF ANY POLICY ISSUED AND THAT ANY WILLFUL CONCEALMENT OR MISREPRESENTATION OF A MATERIAL FACT OR CIRCUMSTANCE SHALL BE GROUNDS TO RESCIND THE INSURANCE.
_______________________________________ Signature of Insured/Applicant-Date _______________________________________ Address of Insured/Applicant