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The New York Anti-Arson Application Form (NYFA-1) serves as a crucial document in the realm of property insurance, particularly for those seeking coverage in high-risk areas. Designed to gather essential information, this form requires applicants to provide details about their property, including its location, insurance amount, and occupancy status. Applicants must identify whether they are owners, tenants, or absentee owners, and they should also disclose the valuation method used to determine the insurance amount. This could include replacement costs or fair market value. Additionally, the form delves into underwriting information, asking pertinent questions about mortgage payments, tax liens, and any outstanding violations related to fire or safety codes. By addressing these factors, the application not only aids insurers in assessing risk but also helps protect property owners from potential fraud. Completing this form accurately is imperative, as any misrepresentation can lead to severe consequences, including policy rescission. Understanding the nuances of this application is essential for anyone involved in property ownership or management in New York.

Similar forms

  • Property Insurance Application: Similar to the NY Anti Arson Application, this document collects essential details about the property, including ownership, occupancy, and insurance coverage. It also requires disclosure of any risks that could affect the property’s insurability.

  • Homeowners Insurance Application: This application is designed for homeowners seeking coverage. It gathers information about the home, personal property, and any previous claims, paralleling the valuation and underwriting information required in the anti-arson application.

  • Commercial Property Insurance Application: This document serves businesses looking to insure their commercial properties. It asks for details about the property’s condition, occupancy rates, and any potential hazards, similar to the underwriting questions in the NY Anti Arson Application.

  • General Liability Insurance Application: This application focuses on the liability aspects of a business or property. It requires information about the operations and risks associated with the property, akin to the risk assessment found in the anti-arson application.

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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 $

 

 

 

 

COST OF SUBSEQUENT IMPROVEMENTS $

 

 

 

 

 

 

 

ESTIMATED REPLACEMENT COST $

 

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[ ] OTHER

 

 

 

 

 

 

 

 

 

 

WHO DETERMINED THE VALUE?

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTACH A COPY OF ANY APPRAISAL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNDERWRITING INFORMATION:

IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS “YES”, COMPLETE THE CORRESPONDING

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBERED SECTION OF PART 2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

1. IS THE APPLICANT OTHER THAN AN INDIVIDUAL OR SOLE PROPRIETORSHIP?

 

 

____

____

 

 

 

2. ARE ANY MORTAGE PAYMENTS (BUILDING OR CONTENTS) OVERDUE BY 3 MONTHS OR MORE?

 

 

____

____

 

 

 

3. ARE THERE ANY REAL ESTATE TAX LIENS OR OTHER TAX LIENS AGAINST THE PROPERTY OR REAL ESTATE TAXES OVERDUE OF ONE YR. OR MORE?

____

____

 

 

 

4. ARE THERE ANY OUTSTANDING RECORDED VIOLATIONS OF FIRE, SAFETY, HEALTH, BUILDING OR CONSTRUCTION CODES AT THIS LOCATION?

____

____

 

5.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?

____

____

6.

IS THE MORTGAGEE OTHER THAN A FEDERAL OR STATE CHARTERED LENDING INSTITUTION?

____

____

7.

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?

____

____

8.

(A) IF THE PROPERTY IS COMMERCIAL, IS MORE THAN 10% OF THE RENTABLE SPACE VACANT, UNOCCUPIED OR SEASONAL?

____

____

 

(B) IF THE PROPERTY IS RESIDENTIAL, ARE 5% OR MORE OF THE APARTMENTS VACANT, UNOCCUPIED OR SEASONAL?

____

____

 

(C) IS WATER, SEWAGE, ELECTRICITY OR HEAT OUT OF SERVICE?

____

____

9.

OTHER POLICIES:

 

 

 

(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?

____

____

10.

HAS THIS PROPERTY BEEN UNDER THE OWNERSHIP OF THE APPLICANT FOR LESS THAN 3 YEARS?

____

____

 

 

 

 

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.

SIGNATURE OF PROPOSED INSURED

TITLE

DATE

_______________________________________________

______________________________

___________________________

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.

FM 101.0.721 (7/82)

STATE OF NEW YORK

ANTI-ARSON APPLICATION

(NYFA-1) PART 2

OWNERSHIP INFORMATION:

 

 

 

 

 

 

1.

LIST THE NAMES AND ADDRESS OF:

SHAREHOLDERS OF A CORPORATION

PARTNERS, INCLUDING LIMITED PARTNERS

TRUSTEES AND BENEFICIARIES

 

NOTE: LIST ONLY THOSE POSSESSING AN OWNERSHIP INTEREST OF 25% OR MORE, EXCEPT FOR CLOSE CORPORATION BENEFICIARIES WHERE ALL

 

OWNERS SHOULD BE LISTED.

 

 

 

 

 

 

NAME

ADDRESS

POSITION

INTEREST %

 

 

 

 

 

 

 

 

 

 

 

 

2.

MORTGAGE PAYMENTS

MORTGAGE _______________________________

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 MORTGAGEES:

7.

LOSSES: LOCATION

_________________________________

DATE

_____________

AMOUNT

____________

DESCRIPTION _______________________

 

_______________________________________________________

_____________________

_______________________

______________________________________

 

_______________________________________________________

_____________________

_______________________

______________________________________

 

_______________________________________________________

_____________________

_______________________

______________________________________

8.VACANCY AND/OR UNOCCUPANCY:

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 THE 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 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.

SIGNATURE OF PROPOSED INSURED

TITLE

DATE

_______________________________________________

______________________________

___________________________

Common mistakes

When completing the New York Anti-Arson Application form, applicants often make several common mistakes that can lead to delays or issues with their insurance coverage. One significant error is failing to accurately identify the applicant's status. The form requires applicants to select from options such as owner, absentee owner, tenant, or other. Not checking the appropriate box can create confusion and potentially invalidate the application.

Another frequent mistake is providing incomplete or incorrect property valuation information. Applicants sometimes neglect to fill in the estimated replacement cost or fair market value. This information is crucial as it helps determine the appropriate amount of insurance. Omitting these details can result in an insurance policy that does not adequately cover the property.

Many applicants also overlook the underwriting questions in Part 1. Each question requires a simple "yes" or "no" response. Failing to answer these questions or answering them inaccurately can lead to complications. For instance, if there are overdue mortgage payments or outstanding tax liens, these must be disclosed. Ignoring these details may not only affect coverage but can also be viewed as an attempt to mislead the insurer.

Furthermore, when it comes to the ownership information section, applicants often forget to list all relevant parties. The form specifies that only those with a 25% or greater ownership interest should be included. However, if any individuals with significant stakes are omitted, it may raise red flags during the underwriting process.

Finally, applicants may fail to provide supporting documentation, such as appraisals or records of previous fire losses. This documentation is essential for validating the information provided in the application. Without it, the insurer may question the accuracy of the application, leading to further delays or denial of coverage.

More About Ny Anti Arson Application

  1. What is the purpose of the New York Anti-Arson Application Form?

    The New York Anti-Arson Application Form (NYFA-1) is required to assess the risk associated with insuring a property. It helps insurance companies determine the appropriate coverage and premium rates based on the property's value, ownership status, and any potential risks related to fire or arson. Completing this form is a crucial step in obtaining insurance coverage for your property.

  2. Who needs to complete the application?

    The application must be completed by the applicant or the insured party. This can include property owners, absentee owners, tenants, or other parties with an interest in the property. Each party must provide accurate information to ensure that the insurance company can properly evaluate the risk.

  3. What information is required on the application?

    The application requires various details, including:

    • Name of the applicant or insured
    • Location of the property
    • Amount of insurance requested
    • Occupancy status (owner, tenant, etc.)
    • Valuation details, including purchase price and estimated replacement cost
    • Underwriting information, such as any overdue mortgage payments or tax liens

    Providing complete and accurate information is essential for a successful application.

  4. What happens if I provide false information?

    Providing false information can have serious consequences. If you knowingly submit inaccurate details, you may be committing a fraudulent insurance act. This can lead to the denial of your claim, cancellation of your policy, or even legal action. Always ensure that the information you provide is truthful and complete.

  5. What should I do if my property details change?

    If there are any changes to the information provided in your application, you must notify your insurer in writing. This should be done either upon renewal of your policy or annually, whichever comes first. Failing to report changes can result in the rescission of your insurance policy.

  6. How do I submit the application?

    You can typically submit the application form directly to your insurance company or agent. Make sure to review the completed form for accuracy before submission. Some insurers may also allow electronic submissions, so check with your insurance provider for specific instructions.

Misconceptions

Misconceptions about the NY Anti-Arson Application Form

  1. Only property owners need to fill out the form. This is incorrect. Tenants and other occupants may also be required to complete the application.
  2. The form is optional. In fact, completing and submitting the application is mandatory under New York Insurance Law.
  3. Providing an estimated replacement cost is unnecessary. This information helps determine the appropriate amount of insurance but does not dictate the value at the time of loss.
  4. All properties are automatically covered once the application is submitted. Coverage is contingent upon approval from the insurance provider after reviewing the application.
  5. There are no consequences for providing false information. Misrepresentation or concealment of material facts can lead to policy rescission and potential legal action.
  6. Only major issues need to be reported. Any changes in the information provided must be reported, regardless of how minor they may seem.
  7. The application process is quick and straightforward. It can be complex and may require extensive documentation, especially for commercial properties.
  8. Once submitted, the application cannot be modified. Applicants can update their information as needed, but they must notify the insurer of changes.
  9. Insurance companies do not check the accuracy of the application. Insurers conduct thorough reviews and may request additional documentation or clarification.
  10. Filling out the application guarantees insurance coverage. Coverage is subject to underwriting approval and may be denied based on the information provided.

Key takeaways

When filling out the New York Anti-Arson Application form (NYFA-1), it is essential to understand the following key points:

  • Complete All Sections: Ensure that every section of the application is filled out accurately. Incomplete applications may lead to delays or denials.
  • Valuation Method: Clearly indicate the method used to establish the amount of insurance. Options include replacement cost, fair market value, or other methods.
  • Disclosure of Information: Be honest when answering questions, particularly those regarding any overdue payments, tax liens, or previous insurance claims. Misrepresentation can lead to severe penalties.
  • Ownership Details: Provide accurate information about all individuals or entities with a significant ownership interest in the property. This includes shareholders, partners, and beneficiaries.
  • Notify of Changes: It is crucial to inform the insurer of any changes in the information provided. This should be done in writing, either at renewal or annually, to avoid potential policy rescission.

Ny Anti Arson Application: Usage Guide

After completing the New York Anti-Arson Application form, the next step involves submitting it to your insurance provider. Ensure that all sections are filled out accurately, as any discrepancies may delay the processing of your application.

  1. Start by entering the name of the applicant or insured at the top of the form.
  2. Provide the location of the property you are insuring.
  3. Indicate the amount of insurance you are applying for in dollars.
  4. Select the appropriate option for the applicant's status (Owner, Absentee Owner, Tenant, or Other).
  5. Fill in the valuation information, including the purchase date, price, cost of improvements, estimated replacement cost, and fair market value.
  6. If applicable, enter the annual rental income for rental properties.
  7. Check the valuation method used to establish the amount of insurance.
  8. Identify who determined the value and attach any relevant appraisal documentation.
  9. Answer the underwriting questions with a “Yes” or “No.” If any answers are “Yes,” complete the corresponding sections in Part 2.
  10. Sign and date the form at the bottom, affirming that the information provided is true.

Once the form is complete, review it for accuracy and ensure that all required attachments are included before submission. This will help facilitate a smoother processing of your application.