Applicant Name:

Mailing  Address:
Num:     St Dir:     St. Name:    St. Type: 

Address Line 2:  (P.O. Box, etc.)

City:         State:        Zip:    

Home Phone  #         Business Phone #

Years at Current Address:

Previous  Address  (If  less than 3 years):

Previous Address Line 2:

Previous City:         State:        Zip:    

Years at Previous Address:

Applicant's Occupation:
(State nature of business if self-employed )

Applicant's Employer Name and Address

City:         State:        Zip:    

Years in Current Occupation:

Years with Current Employer:

Years with Prior Employer:

Marital Status: Date of Birth:  Social Security#:

Co-Applicant's Occupation:
(State nature of business if self-employed )

Co-Applicant's Employer Name and Address:

City:         State:        Zip:    

Years in Current Occupation:

Years with Current Employer:

Years with  Prior Employer:

Marital Status:  Date Of Birth:   Social Security#:

Location of Property
(If different from Mailing Address)
Street #:  St Dir:   St. Name:  St. Type: 

Location Address Line 2:

City:         State:        Zip: 

Approximately how far is the property from the shore?

Is this property a new purchase?

Provide name of prior owner's insurer:

Name of Company canceling or non-renewing policy:

Reason for Cancellation or Non-Renewal:

Policy Number:           Expiration Date:

Is this property insured by NYPIUA?

Policy Number:           Expiration Date:

Do you have flood insurance?

Policy Number:            Expiration Date:

Building Coverage:      Contents Coverage:

HO Form:

Dwelling:                      Other Structures:          

Personal Property:         Loss of Use:

Personal  Liability:         Medical Payments:
(Each Occurrence)        (Each Person)

Construction:     Frame Masonry Fire Resistive              Exterior:  Aluminum Siding Asbestos Siding Brick Masonry Veneer Plastic Siding Stucco Other          Year Built:

Structure Type:  Apartment Condo Co-op Dwelling Townhouse Rowhouse            Usage Type: Primary Secondary Seasonal              Total sq. ft.: 

Num. of Apts:           Num.of Rooms:    Num.of Families:

Num. of Household Residents:                                           Purchase Date:  

Purchase Price: $ Market Value: $ Replacement Cost: $

If Replacement cost applies:

Basement:             Garage:           Breezeway:

Num. of Fire Divisions:     Units in Fire Division:

Protection Device Type      - CENTRAL:

                                              -  DIRECT:

                                              -  LOCAL:

Heat Type: - NONE:

                   - PRIMARY:

                   - SECONDARY:

Oil Storage Tank Location:

Renovation Type - WIRING:

                              - PLUMBING:

                              - HEATING:

                              - ROOFING:

                              - EXTERIOR PAINT:

Dwelling Location Occupied By:  

Dwelling Location Occupied Daily?    YES NO Number of Weeks? 

Visible to Neighbors:     YES NO               Housekeeping Conditions:

Foundation:              CLOSED OPEN NONE                                    Roof Type:     

Deadbolt Lock:       Fire Extinguisher:     Sprinkler: FULL PARTIAL      Fireplaces:  CHIMNEYS HEARTHS PRE-FAB

Swimming Pool:  NO SWIMMING POOL ABOVE GROUND IN GROUND           Approved Fence:           Diving Board: 

Storm Shutters:      NO YES        Hurricane Resistant Glass:   NO YES

Explain all "YES" responses in remarks: (Except question 13,14 and 15)

1. Any farming or other business conducted on premises? (including day/child care)

2. Any residence employees? (Number and type of full and part time employees)

3. Any flooding, brush, forest fire hazard, landslide, etc?

4. Any other residence owned, occupied or rented?

5. Any coverage declined, cancelled or non-renewed during the last 3 years?

6. Has applicant had a foreclosure, repossession or bankruptcy during the past five years?

7. Are there any animals or exotic pets kept on premises? (Note breed and bite history) 

8. Is property located within two miles of tidal water?

9. Is property situated in more than five acres? (If yes, describe land use)

Any losses whether or not paid by insurance, during the last 3 years, at this or at any other location?
If YES , indicate below.

Date

      Type

                  Description of Loss

     Amount

Addl Int Mortgagee     Name & Address:

Addl Int Mortgagee     Name & Address:

List the companies that have declined to insure this property.
Please name the representatives and include their phone numbers:

Broker's Name:

Broker's Mailing  Address:
Num:     St Dir:     St. Name:    St. Type: 

Address Line 2:  (P.O. Box, etc.)

City:       State:     Zip:

Tax Identification Number:

Phone Number:          Fax Number:

E-MAIL Address:

For agents only: Please list the companies with which you have agency contracts:

I  understand that submission of this application to C-MAP does not guarantee placement of insurance coverage. Insurance exists only after all insurer’s application procedures have been completed and a binder has been issued.

Accordingly, I agree to hold harmless C-MAP, the C-MAP Administrator and its voluntary member agents and associations from any and all liability, losses, claims, or expenses that I may incur by reason of their failure or inability for any reason, to obtain insurance coverage on my behalf.

I have read the above application and declare that the information provided in them is true, complete and correct to the best of my knowledge and belief. This information is being offered to the company as an inducement to issue the policy for which I am applying. I realize that an incomplete application or an application submitted without necessary documentation will be returned to me unprocessed.  

ELECTRONIC SIGNATURE:

 *** I certify that the information I have provided in this application is true and correct. I further certify that by inputting my name and the last four digits of my social security number in the appropriate spaces on this web page, I validate this application with an electronic signature unique to me. I agree that signing this application with my electronic signature has the same validity and effect as signing this application by my hand in ink. I authorize New York Property Insurance Underwriting Association, as C-MAP administrator, and any participating company to which this application is sent, to verify any information included in this application for insurance.

I understand and agree that by clicking the SUBMIT button on this web page, I am transferring my application to New York Property Insurance Underwriting Association, as C-MAP administrator, using the internet and I acknowledge and agree that New York Property Insurance Underwriting Association is thus unable to guarantee the privacy and confidentiality of this electronic application. I agree that, regardless of the type of security features used to facilitate the submission of this electronic application, New York Property Insurance Underwriting Association will not be held liable for the interception, transmission failure or other misuse of this electronic application.

If you do not agree to the terms above, you may obtain a paper version of this application and instructions for submission of your application by mail or fax. For more information, contact  New York Property Insurance Underwriting Association at 212-208-9700.    

APPLICANT:

*** PLEASE TYPE YOUR NAME:

LAST 4 DIGITS OF SOCIAL SECURITY #:

DATE:

BROKER OF RECORD:

*** PLEASE TYPE YOUR NAME:

LAST 4 DIGITS OF SOCIAL SECURITY #:

DATE:

Notice of Insurance Information Practices

Personal information about you, including information from a credit report, may be collected from persons other than you in connection with this application and subsequent renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instruction on how to submit a request to us.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of 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 and subjects the person to criminal and substantial civil penalties.