General
Vacant since: ____________ Prior occupancy: __________
Intended plan with property (sale, renovation, rental, etc): _________________________
History of bankruptcy? Yes No Unpaid taxes? Yes No Mortgage paid to date? Yes
No
Any liens (other than mortgage) against the property? Yes No
Check all that apply:
Lapse>12 months Arson or fraud Woodstove/kerosene heater Asbestos/EIFS
Aluminum/knob & tube
Valuation
Replacement cost value: ____________ Sq. footage: ___________ ACV value: _____________
Renovation cost: ____________ Renovations being completed: ____________________________
________________________________________
Other coverage limits being requested?
Coverage B _________________ Coverage C _____________ Liability Limits _________________
Term: 3 Months 6 Months 9 Months 12 Months
Claims History
Losses in last 3-5 years? Yes No Details of claim (DOL, details, paid, open or closed):
____________________________________________________________________________
Does building have current damage? Yes No If yes, provide details: ___________________
_________________________________________________________________________
Applicable in the State of New York: Any person who knowingly and with intent to defraud any insurance company or
other person files and application for insurance or statement of claims 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value
of the claim for each such violation.
