Repair or Replacement Cost Application Supplement

Applicant Information

Name of Applicant:
Applicant's Mailing Address:
Address Line 2: (P.O. Box, etc.)
City: State: Zip:

Producer/Policy Information

Name of Producer :
Producer's Mailing Address:
Address Line 2: (P.O. Box, etc.)
City: State: Zip:
Location of Property requiring Insurance: (if different from mailing address)
Address Line 2: (P.O. Box, etc.)
City: State: Zip:

Voluntary Market Policy

Name of Voluntary Market Company:
Policy/Binder Number :
Effective Date:

Amount of Insurance

Coverage A (Building):	$
Coverage B (Other Structures):	$
Coverage C (Personal Property - HHF):	$

Is the policy written in conjunction with a Voluntary Market Homeowner's policy which includes a State of New York Insurance Department approved wrap-around endorsement?
Does the voluntary market policy include windstorm on the dwelling in excess of the NYPIUA policy?
Does the voluntary market policy include windstorm on the personal property in excess of the NYPIUA policy?

NYPIUA POLICY

Policy/Binder Number :
Effective Date:
What is the amount of insurance you have requested from NYPIUA?	$ Building $ Personal Property (HHF)
Repair or Replacement Cost is being requested for:
Who determined the amount of insurance requested on the NYPIUA policy?
What method was used to determine the repair or replacement cost?

PRODUCER'S STATEMENT / ELECTRONIC SIGNATURE

I hereby certify that I am a licensed agent/broker of New York State. In the event coverage is effective and then cancelled or insurance thereunder terminated or a change is made resulting in a return premium due, I agree to return my proportionate share of commission on such premium.

*** 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 New York State license 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 understand and agree that by clicking the SUBMIT button on this web page, I am transferring repair or replacement cost application supplement data to New York Property Insurance Underwriting Association 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.

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.
No broker or agent has the authority to bind coverage or issue binders on behalf of the Association.

*** Producer's Name:
         License Number:

APPLICANT'S STATEMENT / 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 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, 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.

Sign Form

I(we) certify to the truth of my(our) statements above. I(we) authorize NYPIUA to verify the information contained in this application and to report its transaction to me(us).

Applicant's Signature:
Applicant's Signature:
Last 4 digits of Social Security Number:
Date:

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