North Carolina Business Owners Insurance Application 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 PayrollBusiness Description (What Do You Do)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 Liability Claims in the past 5 years? No Yes ExplainHave there been any Property Claims in the past 5 years? No Yes ExplainCARRIER SPECIFIC GENERAL UNDERWRITINGAre there any premises or operations which are not to be covered by this insurance? No Yes ExplainIs the applicant located in a Condominium? No Yes Has the applicant ever failed to maintain liability or property insurance on this business during the past 5 years? No Yes ExplainHas the applicant(s) (including owners) ever been arrested for any reason? No Yes ExplainAny operations sold, acquired or discontinued in the last 5 years? No Yes ExplainIs the Applicant involved in manufacturing, mixing, relabeling or repacking or products? No Yes ExplainDoes the Applicant sell or distribute foreign product not purchased from a US Distributor? No Yes ExplainDoes the Applicant install, service or assemble any product? No Yes ExplainDoes the Applicant rent or loan equipment to others? No Yes ExplainDoes the Applicant offer any skin tanning services or operate any skin tanning equipment? No Yes ExplainDo any of the buildings have an elevator? No Yes GENERAL LIABILITY UNDERWRITING QUESTIONSAny medical facilities provided or medical professionals employed or contracted? No Yes Do/Have past, present, or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting or hazardous material? No Yes Any operations sold, acquired, or discontinued in the last 5 years? No Yes Any watercraft, docks, floats owned, hired or leased? No Yes Any parking facilities owned/rented? No Yes Is a fee charged for parking? No Yes Are any recreational facilities provided? No Yes Are there any lodging operations including apartments? No Yes Is there a swimming pool on premises? No Yes Are social events sponsored? No Yes Are athletic teams sponsored? No Yes Are there any structural alterations contemplated? No Yes Any demolition expsosure contemplated? No Yes Has Applicant been active in or is currently active in joint ventures? No Yes Do you lease employees to or from other employers? No Yes Is there a labor interchange with any other business or subsidiaries? No Yes Are Day Care Facilities operated or controlled? No Yes Have any crimes occurred or been attempted on your premises within the last three (3) years? No Yes Does the Business' promotional literature make any representations about the safety or security of the premises? No Yes Do you need Products & Completed Operations? No Yes PRODUCTS & COMPLETED OPERATIONSDoes the Applicant install, service or demonstrate products? No Yes Foreign products sold, distributed, used as components? No Yes Research & Development conducted or new products planned? No Yes Guarantee, warranties, hold harmless agreements? No Yes Products related to aircraft/space industry? No Yes Products recalled, discontinued, changed? No Yes Products of others sold or re-packaged under Applicant Label? No Yes Products under label or others? No Yes Vendors coverage required? No Yes Does any named insured sell to other named insureds? No Yes GENERAL LIABILITY SUPPLEMENTAL QUESTIONSWhat Type Of Operation? Contractor (Including Artisan Contractors) Lessor's Risk (Habitational) Lessor's Risk (Commercial) Retail Wholesale Professional Service Manufacturing Has the applicant been in business less than 1 year? No Yes Explain (Include years of experience)Does Applicant draw plans, designs, or specifications for others? No Yes ExplainDo any operations include blasting or utilize or store explosive material? No Yes ExplainDo any operations include excavation, tunneling, underground work or earth moving? No Yes ExplainDo your subcontractors carry coverages or limits less than yours? No Yes Are subcontractors allowed to work without providing you with a Certificate Of Insurance? No Yes Does Applicant lease equipment to others with or without operators? No Yes Will the applicant accept jobs that are solely new roofing or re-roofing? No Yes Has the Applicant ever installed EIFS (Exterior Insulation & Finish Systems) aka synthetic stucco or dryvit to buildings? No Yes Does the Applicant engage in any operations involving aerospace or aircraft parts or perform any work at or in any airport? No Yes Does Applicant understand that there is NO COVERAGE for "Your Work" unless Contractor's Errors & Omissions Coverage is purchased? Yes No Does Applicant understand that there is NO COVERAGE for damage done to other's property unless "Property Damage" is endorsed to the policy? Yes No Do all buildings: have two separate exits from each unit? Yes No Do all buildings: have hard wired smoke detectors with battery backup OR smoke detectors with long life lithium batteries installed in every unit? Yes No Do all buildings: have a fire alarm system? Yes No Do all buildings: have multi-purpose fire extinguishers available in all hallways and common areas? Yes No Does Applicant require written leases of 12 months or greater? Yes No Does Applicant's lease agreement require tenants to carry their own insurance with Certificates provided to the building owner? Yes No Does Applicant have an occupancy rate of 80% or higher? Yes No Do ANY Buildings: allow grilling or other outdoor fires within 10 feet of any structure? Yes No Do ANY Buildings: contain student housing, assisted living, or seasonal/timeshare occupancies? Yes No Do ANY Buildings: have recreational facilities, such as swimming pools, exercise equipment, playground, tennis court, dock/boat slip, etc? Yes No Do ANY Buildings: have a lake, pond, or reservoir on premises? Yes No Do You Need Coverage For Any Property? (Buildings, Equipment, Etc) Yes No PROPERTY SECTIONInsured's Interest In Property Building Owner Tenant Part Occupied by Applicant Entire Partial None Year Of Construction Square Footage Of Building Construction TypeMasonry VeneerMasonry Non CombustibleJoisted MasonryFrameOtherNumber of Stories Fire Alarm TypeLocalCentral StationNoneBurglar Alarm TypeLocalCentral StationNoneSprinkler System (Percent Sprinklered)100%0%OtherDoes the premises have deep frying/grilling? No Yes Has The Building Been Updated? Yes No I don't know Year HVAC Renovated Year Electrical Renovated Year Plumbing Renovated Year Roof Renovated Δ
