Md. Code Regs. 31.08.01.03
Current through Register Vol. 51, No. 24, December 2, 2024
Section 31.08.01.03 - Standard Antiarson Application-Part 1NAME 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
Md. Code Regs. 31.08.01.03