North Carolina Business Auto Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*AJ BrowerJared BellmundHeather BaileyJack WingateMike ReeseBill HeasleyJeff HallEd JohnsonINSURED INFORMATIONApplicant Name (Name of Business) Primary Contact* First Last Mobile Phone*Primary Email* Are Mailing & Location Address Different No Yes Mailing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are there additional locations? No Yes List other locations (include full address)Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal ID Number of years in business Number of Employees Annual RevenueAnnual PayrollCOMMERCIAL GENERAL UNDERWRITINGIs the Applicant a Subsidiary of another entity? No Yes Explain (Give Name Of Entity)Does the Applicant have any subsidiaries? No Yes ExplainIs a formal safety program in operation? No Yes ExplainAny Exposure to flammables, explosives, chemicals, or Radioactive/nuclear materials? No Yes ExplainAny policy or coverage declined, cancelled or non-renewed during the prior 3 years? No Yes ExplainAny past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? No Yes ExplainDuring the last 5 years, has any applicant been indicted for, or convicted of any degree of the crime of fraud, bribery, arson or any other arson related crime? No Yes Any uncorrected fire and/or safety code violations? No Yes ExplainHas Applicant had a foreclosure, repossession, bankruptcy (or filed for bankruptcy), judgement, or lien in the past 5 years? No Yes ExplainHas the business been placed in a trust? No Yes ExplainAny foreign operations, foreign products distributed in USA, or US products sold / distributed in foreign countries? No Yes ExplainDoes Applicant own / lease / operate any drones? No Yes ExplainDoes Applicant hire others to operate drones? No Yes ExplainPRIOR CLAIMSHave there been any Claims in the past 5 years? No Yes ExplainBUSINESS AUTO UNDERWRITINGWith the exception of any encumberances, are any vehicles for which insurance is requested NOT solely owned by and registered to the application? No Yes Do OVER 50% of the employees use their autos in the business? No Yes Is there a vehicle maintenance program in operation? No Yes Are any vehicles leased to others? No Yes Any vehicle modified / or include special equipment? No Yes Explain (include description and value)Are ICC, PUC, or Other Filings required? No Yes Do operations involve transporting hazardous material? No Yes Any Hold Harmless Agreements? No Yes Any vehicles used by family members? No Yes Does the applicant obtain MVR Verifications of all drivers? No Yes Does the applicant have a specific driver recruiting method? No Yes Are any drivers not covered by workers compensation? No Yes Any vehicles owned but not scheduled on this application? No Yes Any drivers with convictions for moving traffic violations? No Yes Are all vehicles to be included in this policy part of a fleet? No Yes Do you have electronic monitoring devices that record and transmit data in any of your vehicles? No Yes CARRIER SPECIFIC UNDERWRITINGI (applicant) certify that all vehicles are registered in the following state AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Are all vehicles principally garaged at the business address? Yes No In the applicant required to comply with Motor Carrier Act of 1980 (MCS90)? No Yes (DRIVER QUESTIONS) HAS ANY DRIVER...Had any auto insurance refused, cancelled or expired in the past 5 years or been excluded or restricted on a policy in past 5 years? No Yes Been required to file evidence of financial responsibility in the past 5 years? No Yes Had their driver's license revoked or suspended in past 5 years? No Yes Received a ticket for speeding, a PJC, or any other vehicle code violation within the past 5 years? No Yes Ever been arrested for ANY reason? No Yes Had a physical or mental impairment or disability or other medical infirmity? No Yes Had any comprehensive losses (deer, glass breakage, fire, theft, etc) in the past 5 years? No Yes While driving a motor vehicle, been involved in an accident or reported a claim to an insurance company during the past 5 years? No Yes Δ
