New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter III - Policy and Certificate Provisions
Subchapter B - Property and Casualty Insurance
Part 62 - FIRE INSURANCE
Subpart 62-4 - Anti-arson Application
Section 62-4.2 - Anti-arson application

(1) Every insurer, broker or agent shall furnish to all applicants for insurance subject to this Subpart an anti-arson application, containing at least the information requested in subdivisions (c) and (d) of this section, prior to or at the time the risk is submitted or bound.

(2) Unless the insured returns the completed, signed and affirmed anti-arson application to the insurer, broker or agent within 45 days of the effective date of coverage, the insurer shall cancel such coverage by giving written notice to the insured and to the designated mortgagee not named as the insured in the policy or binder in accordance with subsection (b) of section 3426 of the Insurance Law. If the policy covers nonowner-occupied buildings used predominantly for residential purposes which consist of not more than four dwelling units, such notice shall comply with the provisions of subsection (b) of section 3425 of the Insurance Law.

(1) At least 45 days but not more than 60 days in advance of the expiration date of a policy subject to this Subpart, or the annual renewal date of a policy covering nonowner-occupied buildings used predominantly for residential purposes which consist of not more than four dwelling units, every insurer shall deliver an anti-arson application to the named insured at the mailing address shown on the policy or to the insured's agent or broker.

(2) If the insured fails to return the completed, signed and affirmed anti-arson application to the insurer prior to the expiration date of the policy, the insurer shall cancel the policy in accordance with section 3426 (c)(1)(G) of the Insurance Law. If the insured of a policy covering nonowner-occupied buildings used predominantly for residential purposes which consist of not more than four dwelling units fails to return the completed, signed and affirmed anti-arson application to the insurer prior to the annual renewal date of the policy, the policy shall be canceled in accordance with section 3425 (c)(2)(F) of the Insurance Law.

1. List the names and addresses of:

2. Mortgage Payments: Mortgagee________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 Mortgagee(s):____________

____________

7. Losses:

Location Date Amount Description

________ ________ $________ ____________

________ ________ ________ ____________

________ ________ ________ ____________

8. Vacancy and/or unoccupanycy:

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 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 AN APPLICATION FOR INSURANCE CONTAINING ANY 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 RESCIND THE INSURANCE POLICY.