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 [ ] 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. Purchase Information: Date _________________ Price $_______ Estimated Replacement Cost $_____________________________ For rental properties, indicate the Annual Rental Income Check the valuation method used to establish the amount of insurance: Who determined the value?________________________________ UNDERWRITING INFORMATION: If the answer to any of the following is “yes”, complete Part 2. Is the applicant other than an individual or sole proprietorship? Are there any taxes unpaid or overdue for 1 or more years? Are there any tax liens against the property or business? 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? Is the mortgagee other than a federal or State chartered lending institution? 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? Is any portion of the building or any apartment vacant, unoccupied, or used on a seasonal basis? Has any coverage or policy on this property been declined, cancelled, or nonrenewed in the last 3 years? Is there any other insurance in force or to be secured on this property? Has the applicant owned this property for less than 3 years? 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