31.08.01.03

.03 Standard Antiarson Application—Part 1.

STATE OF MARYLAND
STANDARD ANTIARSON APPLICATION
PART I

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.

1. Purchase Information: Date _________________ Price $_______

Cost of Subsequent Improvements $________________________

2. Estimated Replacement Cost $_____________________________

Estimated Fair Market Value (exclusive of land) $_______

3. For rental properties, indicate the Annual Rental Income

$_____________________________________________________________

4. 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 (Describe)______________________________________

5. Who determined the value?________________________________

Attach a copy of any appraisal.

B. UNDERWRITING INFORMATION: If the answer to any of the following is "yes", complete Part 2.

1. Is the applicant other than an individual or sole proprietorship?

Yes [ ] No [ ]

2. Are there any taxes unpaid or overdue for 1 or more years?

Yes [ ] No [ ]

3. Are there any tax liens against the property or business?

Yes [ ] No [ ]

4. Has anyone with a financial interest in this property been convicted for arson, fraud, or other crime related to loss on property owned now or during the last 10 years?

Yes [ ] No [ ]

5. Is the mortgagee other than a federal or State chartered lending institution?

Yes [ ] No [ ]

6. Have there been losses over the last 10 years with regard to any property in which the applicant held a substantial financial interest including a partnership interest or a mortgage and where any fire loss was in excess of 25% of the insured value?

Yes [ ] No [ ]

7. Is any portion of the building or any apartment vacant, unoccupied, or used on a seasonal basis?

Yes [ ] No [ ]

8. Has any coverage or policy on this property been declined, cancelled, or nonrenewed in the last 3 years?

Yes [ ] No [ ]

9. Is there any other insurance in force or to be secured on this property?

Yes [ ] No [ ]

10. Has the applicant owned this property for less than 3 years?

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