(a) Revised Claim Form NYFC-1 (Part 3) contained in this section shall be used to comply with this Subpart.

(b) Supplemental Fire Claim Form (Part 3).

NYS SUPPLEMENTAL FIRE CLAIM FORM (NYFC-1) PART 3—REVISED (1989)

Insured Location:

(number & street address) (city) (state) (zip code)

Location of Fire:

(number & street address) (city) (state) (zip code)

Date of Fire: ___ / __ /19 _ Named Insured:

(month) (day)

Insurance Co. (NAIC Code): ______ Agent/Adjuster (NY Lic. No.):

Public Adjuster (NY Lic. No.): ______ Policy No.:

Policy Claim No.: ________ Limit of Policy: $

Ownership Information

List the name and address of: (a) any person with an interest of five (5) percent or more in the proceeds of the claim: (b) any mortgagee, vendee in possession, receiver, executor or trustee (including the beneficiaries of the trust), all partners in partnership including limited partners; (c)all officers and directors of a corporation; and (d) any person with an interest of ten (10) percent or more of the issued outstanding stock of a corporation.(*)

Name Address Position Interest %

Signature ________________ Date

(*) Other than a banking organization as defined in Section 2 of the Banking Law, a national bank association, a federal saving & loan association, the mortgage facilities corporation, savings bank life insurance fund, the savings bank retirement system, an authorized insurer as defined in Section 107 of the Insurance Law or a trust company or other corporation organized under the laws of this State or the capital stock of which is owned by at least 20 savings banks or by at least 20 savings and loan associations or a subsidiary corporation all of the capital stock of which is owned by such trust company or other corporation or a corporation the shares of which are listed on a national securities exchange or regularly quoted in over-the-counter market by one or more members of a national or affiliated securities association

BFI Job No.________