STATE OF MARYLAND STANDARD ANTIARSON APPLICATION PART I NAME OF APPLICANT/INSURED ______________________________________ LOCATION OF STRUCTURE __________________________________________ PRESENT OCCUPANCY OF STRUCTURE _________________________________ Amount of Insurance __________ Applicant is: Owner Occupant [ ] Absentee Owner [ ] Tenant [ ]

1. 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. 1. Purchase Information: Date _________________ Price $_______ Cost of Subsequent Improvements $________________________
   2. 2. Estimated Replacement Cost $_____________________________ Estimated Fair Market Value (exclusive of land) $_______
   3. 3. For rental properties, indicate the Annual Rental Income $_____________________________________________________________
   4. 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. 5. Who determined the value?________________________________ Attach a copy of any appraisal.

2. B. UNDERWRITING INFORMATION: If the answer to any of the following is “yes”, complete Part 2.

   1. 1. Is the applicant other than an individual or sole proprietorship? Yes [ ] No [ ]
   2. 2. Are there any taxes unpaid or overdue for 1 or more years? Yes [ ] No [ ]
   3. 3. Are there any tax liens against the property or business? Yes [ ] No [ ]
   4. 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. 5. Is the mortgagee other than a federal or State chartered lending institution? Yes [ ] No [ ]
   6. 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. 7. Is any portion of the building or any apartment vacant, unoccupied, or used on a seasonal basis? Yes [ ] No [ ]
   8. 8. Has any coverage or policy on this property been declined, cancelled, or nonrenewed in the last 3 years? Yes [ ] No [ ]
   9. 9. Is there any other insurance in force or to be secured on this property? Yes [ ] No [ ]
   10. 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

Authority: Insurance Article, §2-109 and Title 19, Subtitle 3, Annotated Code of Maryland

Effective date: June 1, 1983 (10:6 Md. R. 556)

Chapter recodified from COMAR 09.30.60 to COMAR 31.08.01effective September 7, 1998 (25:18 Md. R. 1439)

Regulation .02A—C amended effective January 1, 2018 (44:4 Md. R. 256)