NY Anti-Arson Application Form PDF Details

The State of New York Anti-Arson Application (NYFA-1) is a critical document designed to mitigate the risk of fire-setting incidents for properties seeking insurance coverage. This application is mandated by Section 168-j of the New York Insurance Law and Insurance Department Regulation 96, highlighting its importance in the insurance process. It requires detailed information from the applicant or the insured, ranging from the name and location of the property to the amount of insurance desired. Applicants must disclose their relationship to the property—whether as owner-occupants, absentee owners, tenants, or in other capacities— and provide valuation information that helps explain the chosen insurance amount. The form also delves into purchase information, including the date and price of purchase, costs of subsequent improvements, estimated replacement cost, and the estimated fair market value excluding land. For rental properties, the annual rental income must be indicated. Critical to the application are the underwriting information sections, which inquire about the property's financial status, such as overdue mortgage payments, tax liens, outstanding recorded violations, and whether the property or any party with a financial interest has been involved in arson, fraud, or other related crimes in the past five years. Additionally, it examines the mortgagee's nature, property's insurance history, occupancy details, and any other policies on the property. The form sternly warns against providing false information, emphasizing that fraudulent acts could lead to legal consequences and rescission of the insurance policy. The comprehensive nature of the NY Anti-Arson Application underscores the state's commitment to preventing arson and ensuring that properties are insured under genuine and transparent circumstances.

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Form Name NY Anti-Arson Application Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names anti arson application, ny anti arson, anti arson application pdf, state farm 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

_______________________________________________

______________________________

___________________________

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state nyfa completion process shown (stage 1)

2. Right after the first section is done, go to enter the applicable information in all these: ON PROPERTY DURING THE LAST YEARS, HAVE THERE BEEN FIRE LOSSES DURING, OTHER POLICIES, a IS THERE ANY OTHER INSURANCE IN, HAS THIS PROPERTY BEEN UNDER THE, YES, ANY PERSON WHO KNOWINGLY AND WITH, SIGNATURE OF PROPOSED INSURED, TITLE, DATE, and INSUREDS SHALL NOTIFY THE INSURER.

Stage no. 2 of filling out state nyfa

3. Completing NAME, ADDRESS, POSITION, INTEREST, TOTAL UNITS, VACANCY UNOCCUPANCY, DATE DUE AMOUNT DUE, DATE DUE AMOUNT DUE, DESCRIBE, DESCRIBE, NAME OF PERSON, AMOUNT, DESCRIPTION, TYPE, and DATE is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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Many people generally make mistakes while completing AMOUNT in this part. Don't forget to revise everything you enter here.

4. The following paragraph needs your details in the subsequent parts: LIST ANY OTHER ENCUMBRANCES UNPAID, MORTGAGE PAYMENTS MORTGAGE, NAME OF SELLER, DATE, SELLING PRICE, AMOUNT OF INSURANCE, REASON FOR VACANCYUNOCCUPANCY, CARRIER, DATE, AMOUNT OF MORTGAGE, MORTGAGEE, YES, and POLICY. Be sure that you type in all of the needed info to move forward.

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Best ways to prepare state nyfa portion 5

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