STATE OF MARYLAND STANDARD ANTIARSON APPLICATION PART 2

1. A. Ownership Information:

   1. 1. Check the type of ownership for the insured property: [ ] Shareholders of a corporation [ ] Trustees and beneficiaries [ ] Partners, including limited partners [ ] Sole proprietorship
   2. 2. Complete the following for all those possessing an ownership interest of 10% or more, except that all owners should be listed for closed corporations and beneficiaries. NAME ADDRESS POSITION INTEREST ____________________________________________________________________________

   3. 3. Have any of the owners listed above:

      1. a. Within the past ten years, claimed any fire loss for the destruction of 25% or more of any insured property? Yes [ ] No[ ] If Yes, complete the following:

         Location	Date	Amount of Loss	Description of Loss
         ________________	________	______________	_________________________
         ________________	________	______________	_________________________

      2. b. Been convicted of any crimes? Yes [ ] No[ ] If Yes, complete the following:

         Name	Date	Offense
         _________________________	______	________________________________

   4. 4. Mortgage Payments: Mortgagee___________________ Monthly Payment____________ Amount Past Due__________________________________________ List any other encumbrances______________________________
   5. 5. Unrecorded Mortgages: Name of Mortgagee:_______________________________________ Explanation______________________________________________
   6. 6. Taxes (include Real Estate, Water, Sewer, Special Privilege, etc.): Annual Amount Due_______________ Amount Past Due_________
   7. 7. Is the building for sale? Yes [ ] No[ ] If yes, date put up for sale: ____________

2. B. Vacancy.

   1. 1. Indicate seasonal period (if any) when building is unused: _________________________________________________
   2. 2. For apartment buildings indicate: Total units_______ Unoccupied units_____
   3. 3. For other buildings indicate percent vacant:_____

   4. 4. For all buildings indicate the following:

      1. a. Reason for vacancy/unoccupancy:______________
      2. b. Anticipated date of occupancy:_______________
      3. c. If the building is vacant or unoccupied, indicate how it is protected from unauthorized entry_________________

   ________________________________________________________

3. C. Additional Property Description:

   1. 1. Is water, sewage, electricity, or heat out of service? Yes [ ] No[ ] If yes, explain__________________________________________
   2. 2. Is there unrepaired damage or have items been stripped from the building? Yes [ ] No[ ] If yes, describe:__________________________________________
   3. 3. Are any violations outstanding with regard to the Fire, Building or Health Code? Yes [ ] No[ ]
   4. 4. Is there a governmental order to vacate or destroy the building or has the building been classified uninhabitable or structurally unsafe? Yes [ ] No[ ]

4. D. Other Policies:

   1. 1. List all other policies which insure this property against fire loss:

      Status	Date	Amount of Insurance	Carrier	Policy #
      ______	______	___________________	_________	________

   2. 2. List all real estate transactions during last 3 years involving this property:

      Date	Selling Price	Name of Seller	Amount of Mortgage	Mortgagee
      _____	_______	_______________	________	_____________

      Witness—Date	Signature—Date
      _______________________________	__________________________

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)