North Carolina Business Owners Insurance ApplicationINSURED INFORMATIONApplicant Name (Name of Business)Primary Contact First Last Mobile PhonePrimary 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 PayrollBusiness Description (What Do You Do)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 Liability Claims in the past 5 years?NoYesExplainHave there been any Property Claims in the past 5 years?NoYesExplainCARRIER SPECIFIC GENERAL UNDERWRITINGAre there any premises or operations which are not to be covered by this insurance?NoYesExplainIs the applicant located in a Condominium?NoYesHas the applicant ever failed to maintain liability or property insurance on this business during the past 5 years?NoYesExplainHas the applicant(s) (including owners) ever been arrested for any reason?NoYesExplainAny operations sold, acquired or discontinued in the last 5 years?NoYesExplainIs the Applicant involved in manufacturing, mixing, relabeling or repacking or products?NoYesExplainDoes the Applicant sell or distribute foreign product not purchased from a US Distributor?NoYesExplainDoes the Applicant install, service or assemble any product?NoYesExplainDoes the Applicant rent or loan equipment to others?NoYesExplainDoes the Applicant offer any skin tanning services or operate any skin tanning equipment?NoYesExplainDo any of the buildings have an elevator?NoYesGENERAL LIABILITY UNDERWRITING QUESTIONSAny medical facilities provided or medical professionals employed or contracted?NoYesDo/Have past, present, or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting or hazardous material?NoYesAny operations sold, acquired, or discontinued in the last 5 years?NoYesAny watercraft, docks, floats owned, hired or leased?NoYesAny parking facilities owned/rented?NoYesIs a fee charged for parking?NoYesAre any recreational facilities provided?NoYesAre there any lodging operations including apartments?NoYesIs there a swimming pool on premises?NoYesAre social events sponsored?NoYesAre athletic teams sponsored?NoYesAre there any structural alterations contemplated?NoYesAny demolition expsosure contemplated?NoYesHas Applicant been active in or is currently active in joint ventures?NoYesDo you lease employees to or from other employers?NoYesIs there a labor interchange with any other business or subsidiaries?NoYesAre Day Care Facilities operated or controlled?NoYesHave any crimes occurred or been attempted on your premises within the last three (3) years?NoYesDoes the Business' promotional literature make any representations about the safety or security of the premises?NoYesDo you need Products & Completed Operations?NoYesPRODUCTS & COMPLETED OPERATIONSDoes the Applicant install, service or demonstrate products?NoYesForeign products sold, distributed, used as components?NoYesResearch & Development conducted or new products planned?NoYesGuarantee, warranties, hold harmless agreements?NoYesProducts related to aircraft/space industry?NoYesProducts recalled, discontinued, changed?NoYesProducts of others sold or re-packaged under Applicant Label?NoYesProducts under label or others?NoYesVendors coverage required?NoYesDoes any named insured sell to other named insureds?NoYesGENERAL LIABILITY SUPPLEMENTAL QUESTIONSWhat Type Of Operation?Contractor (Including Artisan Contractors)Lessor's Risk (Habitational)Lessor's Risk (Commercial)RetailWholesaleProfessional ServiceManufacturingHas the applicant been in business less than 1 year?NoYesExplain (Include years of experience)Does Applicant draw plans, designs, or specifications for others?NoYesExplainDo any operations include blasting or utilize or store explosive material?NoYesExplainDo any operations include excavation, tunneling, underground work or earth moving?NoYesExplainDo your subcontractors carry coverages or limits less than yours?NoYesAre subcontractors allowed to work without providing you with a Certificate Of Insurance?NoYesDoes Applicant lease equipment to others with or without operators?NoYesWill the applicant accept jobs that are solely new roofing or re-roofing?NoYesHas the Applicant ever installed EIFS (Exterior Insulation & Finish Systems) aka synthetic stucco or dryvit to buildings?NoYesDoes the Applicant engage in any operations involving aerospace or aircraft parts or perform any work at or in any airport?NoYesDoes Applicant understand that there is NO COVERAGE for "Your Work" unless Contractor's Errors & Omissions Coverage is purchased?YesNoDoes Applicant understand that there is NO COVERAGE for damage done to other's property unless "Property Damage" is endorsed to the policy?YesNoDo all buildings: have two separate exits from each unit?YesNoDo all buildings: have hard wired smoke detectors with battery backup OR smoke detectors with long life lithium batteries installed in every unit?YesNoDo all buildings: have a fire alarm system?YesNoDo all buildings: have multi-purpose fire extinguishers available in all hallways and common areas?YesNoDoes Applicant require written leases of 12 months or greater?YesNoDoes Applicant's lease agreement require tenants to carry their own insurance with Certificates provided to the building owner?YesNoDoes Applicant have an occupancy rate of 80% or higher?YesNoDo ANY Buildings: allow grilling or other outdoor fires within 10 feet of any structure?YesNoDo ANY Buildings: contain student housing, assisted living, or seasonal/timeshare occupancies?YesNoDo ANY Buildings: have recreational facilities, such as swimming pools, exercise equipment, playground, tennis court, dock/boat slip, etc?YesNoDo ANY Buildings: have a lake, pond, or reservoir on premises?YesNoDo You Need Coverage For Any Property? (Buildings, Equipment, Etc)YesNoPROPERTY SECTIONInsured's Interest In PropertyBuilding OwnerTenantPart Occupied by ApplicantEntirePartialNoneYear Of ConstructionSquare Footage Of BuildingConstruction TypeMasonry VeneerMasonry Non CombustibleJoisted MasonryFrameOtherNumber of StoriesFire Alarm TypeLocalCentral StationNoneBurglar Alarm TypeLocalCentral StationNoneSprinkler System (Percent Sprinklered)100%0%OtherDoes the premises have deep frying/grilling?NoYesHas The Building Been Updated?YesNoI don't knowYear HVAC RenovatedYear Electrical RenovatedYear Plumbing RenovatedYear Roof Renovated This iframe contains the logic required to handle Ajax powered Gravity Forms. ShareFacebookTwitterLinkedInMorePinterestRedditEmailPrint
