New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 62 - FIRE INSURANCE › Subpart 62-5 - Supplemental Fire Claim Form › Section 62-5.6 - Supplemental claim form

Current through Register Vol. 46, No. 28, July 10, 2024
(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.________
						......................................................................................................................