North Carolina Business Auto Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*Jack WingateMichael ReeseJared BellmundAJ BrowerWilliam HeasleyINSURED INFORMATIONApplicant Name (Name of Business)Primary Contact* First Last Mobile Phone*Primary Email* Are Mailing & Location Address DifferentNoYesMailing 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?NoYesList other locations (include full address)Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal IDNumber of years in businessNumber of EmployeesAnnual RevenueAnnual PayrollCOMMERCIAL GENERAL UNDERWRITINGIs the Applicant a Subsidiary of another entity?NoYesExplain (Give Name Of Entity)Does the Applicant have any subsidiaries?NoYesExplainIs a formal safety program in operation?NoYesExplainAny Exposure to flammables, explosives, chemicals, or Radioactive/nuclear materials?NoYesExplainAny policy or coverage declined, cancelled or non-renewed during the prior 3 years?NoYesExplainAny past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?NoYesExplainDuring 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?NoYesAny uncorrected fire and/or safety code violations?NoYesExplainHas Applicant had a foreclosure, repossession, bankruptcy (or filed for bankruptcy), judgement, or lien in the past 5 years?NoYesExplainHas the business been placed in a trust?NoYesExplainAny foreign operations, foreign products distributed in USA, or US products sold / distributed in foreign countries?NoYesExplainDoes Applicant own / lease / operate any drones?NoYesExplainDoes Applicant hire others to operate drones?NoYesExplainPRIOR CLAIMSHave there been any Claims in the past 5 years?NoYesExplainBUSINESS AUTO UNDERWRITINGWith the exception of any encumberances, are any vehicles for which insurance is requested NOT solely owned by and registered to the application?NoYesDo OVER 50% of the employees use their autos in the business?NoYesIs there a vehicle maintenance program in operation?NoYesAre any vehicles leased to others?NoYesAny vehicle modified / or include special equipment?NoYesExplain (include description and value)Are ICC, PUC, or Other Filings required?NoYesDo operations involve transporting hazardous material?NoYesAny Hold Harmless Agreements?NoYesAny vehicles used by family members?NoYesDoes the applicant obtain MVR Verifications of all drivers?NoYesDoes the applicant have a specific driver recruiting method?NoYesAre any drivers not covered by workers compensation?NoYesAny vehicles owned but not scheduled on this application?NoYesAny drivers with convictions for moving traffic violations?NoYesAre all vehicles to be included in this policy part of a fleet?NoYesDo you have electronic monitoring devices that record and transmit data in any of your vehicles?NoYesCARRIER 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?YesNoIn the applicant required to comply with Motor Carrier Act of 1980 (MCS90)?NoYes(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?NoYesBeen required to file evidence of financial responsibility in the past 5 years?NoYesHad their driver's license revoked or suspended in past 5 years?NoYesReceived a ticket for speeding, a PJC, or any other vehicle code violation within the past 5 years?NoYesEver been arrested for ANY reason?NoYesHad a physical or mental impairment or disability or other medical infirmity?NoYesHad any comprehensive losses (deer, glass breakage, fire, theft, etc) in the past 5 years?NoYesWhile driving a motor vehicle, been involved in an accident or reported a claim to an insurance company during the past 5 years?NoYes ShareFacebookTwitterLinkedInMorePinterestRedditEmailPrint
