.04 Standard Antiarson Application—Part 2.


A. Ownership Information:

1. Check the type of ownership for the insured property:

[ ] Shareholders of a corporation

[ ] Trustees and beneficiaries

[ ] Partners, including limited partners

[ ] Sole proprietorship

2. Complete the following for all those possessing an ownership interest of 10% or more, except that all owners should be listed for closed corporations and beneficiaries.



3. Have any of the owners listed above:

a. Within the past ten years, claimed any fire loss for the destruction of 25% or more of any insured property?

Yes [ ] No[ ]

If Yes, complete the following:

Location Date Amount of Loss Description of Loss
________________ ________ ______________ _________________________
________________ ________ ______________ _________________________

b. Been convicted of any crimes?

Yes [ ] No[ ]

If Yes, complete the following:

Name Date Offense
_________________________ ______ ________________________________

4. Mortgage Payments:

Mortgagee___________________ Monthly Payment____________

Amount Past Due__________________________________________

List any other encumbrances______________________________

5. Unrecorded Mortgages:

Name of Mortgagee:_______________________________________


6. Taxes (include Real Estate, Water, Sewer, Special Privilege, etc.):

Annual Amount Due_______________ Amount Past Due_________

7. Is the building for sale?

Yes [ ] No[ ]

If yes, date put up for sale: ____________

B. Vacancy.

1. Indicate seasonal period (if any) when building is unused:


2. For apartment buildings indicate:

Total units_______ Unoccupied units_____

3. For other buildings indicate percent vacant:_____

4. For all buildings indicate the following:

a. Reason for vacancy/unoccupancy:______________

b. Anticipated date of occupancy:_______________

c. If the building is vacant or unoccupied, indicate how it is protected from unauthorized entry_________________

C. Additional Property Description:

1. Is water, sewage, electricity, or heat out of service?

Yes [ ] No[ ]

If yes, explain__________________________________________

2. Is there unrepaired damage or have items been stripped from the building?

Yes [ ] No[ ]

If yes, describe:__________________________________________

3. Are any violations outstanding with regard to the Fire, Building or Health Code?

Yes [ ] No[ ]

4. Is there a governmental order to vacate or destroy the building or has the building been classified uninhabitable or structurally unsafe?

Yes [ ] No[ ]

D. Other Policies:

1. List all other policies which insure this property against fire loss:

Status Date Amount of
Carrier Policy #
______ ______ ___________________ _________ ________

2. List all real estate transactions during last 3 years involving this property:

Date Selling Price Name of
Amount of
_____ _______ _______________ ________ _____________
Witness—Date Signature—Date
_______________________________ __________________________