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 62-5 - Supplemental Fire Claim Form
Section 62-5.6 - Supplemental claim form
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Revised Claim Form NYFC-1 (Part 3) contained in this section shall be used to comply with this Subpart.
(b) Supplemental Fire Claim Form (Part 3).
NYS SUPPLEMENTAL FIRE CLAIM FORM (NYFC-1) PART 3-REVISED (1989)
Insured Location: ......................................................................................................................
......................................................................................................................
(number & street address)
......................................................................................................................
(city)
......................................................................................................................
(state)
(zip code)
Location of Fire: ......................................................................................................................
......................................................................................................................
(number & street address)
......................................................................................................................
(city)
......................................................................................................................
(state)
(zip code)
Date of Fire: ___
/ __ /19 _ Named Insured: ......................................................................................................................
..(month) (day) ......................................................................................................................
Insurance Co. (NAIC Code): ______ Agent/Adjuster (NY Lic. No.): + ......................................................................................................................
Public Adjuster (NY Lic. No.): ______ ......................................................................................................................
Policy No.: ......................................................................................................................
Policy Claim No.: ________ Limit of Policy: $ ......................................................................................................................
Ownership Information
List the name and address of:
Name
......................................................................................................................
Address
......................................................................................................................
Position
Interest %
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
Signature ________________ Date .................................
(*) Other than a banking organization as defined in Section 2 of the Banking Law, a national bank association, a federal saving & loan association, the mortgage facilities corporation, savings bank life insurance fund, the savings bank retirement system, an authorized insurer as defined in Section 107 of the Insurance Law or a trust company or other corporation organized under the laws of this State or the capital stock of which is owned by at least 20 savings banks or by at least 20 savings and loan associations or a subsidiary corporation all of the capital stock of which is owned by such trust company or other corporation or a corporation the shares of which are listed on a national securities exchange or regularly quoted in over-the-counter market by one or more members of a national or affiliated securities association
BFI Job No.________ ......................................................................................................................