North Carolina Business Umbrella 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 UMBRELLA UNDERWRITINGUnderlying InsuranceUnderlying Insurance NOT with ALLCHOICE Automobile Liability General Liability Workers Compensation AUTOB Carrier | Policy Number AUTOB Effective Date Month Day Year AUTOB Liability Limit $1,000,000 CSL $750,000 CSL $500,000 CSL $300,000 CSL < $300,000 CSL AUTOB Annual PremiumCGL Carrier | Policy Number CGL Effective Date Month Day Year CGL Liability Limit > $2,000,000 Agg | $1,000,000 Occ $2,000,000 Agg | $1,000,000 Occ $1,000,000 Agg | $500,000 Occ $500,000 Agg | $500,000 Occ < $500,000 Agg | $500,000 Occ CGL Annual PremiumWORK Carrier | Policy Number WORK Effective Date Month Day Year WORK Liability Limit $1M | $1M | $1M $500K | $500K | $500K $100K | $500K | $100K WORK Annual PremiumDo You Have Employee Benefits Liability Coverage No Yes Name Of Benefit Program Limit Of Insurance (Ea Employee)Aggregate Limit For EBLRetained Limit For EBLRetroactive Date For EBL Month Day Year 1. Are Defense Costs: Within Aggregate Limits? A Separate Limit? Unlimited? I don't know 2. Indicate the Edition Date of the ISO form or similar filing for the underlying coverage If you don't know - Mark "NA"3. Has any product, work, accident or location been excluded, uninsured or self-insured from any previous coverage? No Yes 4. For CLAIMS MADE, indicate Retroactive Date of current underlying policy: (leave blank if not Claims Made) MM slash DD slash YYYY 5. For CLAIMS MADE, indicate entry date into uninterrupted Claims Made Coverage: (leave blank if not claims made) Month Day Year 6. For CLAIMS MADE, was "TAIL" coverage purchased for any previous primary or excess policy? NA Yes No Effective Date Of Tail Coverage Month Day Year Coverage & Exposure (Check coverage in underlying policies & also check if any exposure)Check If Appropriate \ Coverage Exists Auto Liability CGL - Claims Made CGL - Occurrence Check If Coverage And/Or Exposure Is Present Advertisers Liability Additional Interests Aircraft Liability Aircraft Passenger Liability Apartments | Condos | Hotels | Motels Care, Custody, Control Contractors Liability Employee Benefit Liability Foreign Liability / Travel Garagekeepers Liability Incidental Medical Malpractice Liquor Liability Pollution Liability Product Liability Professional Liability (E&O) Protective Liability Vendors Liability Watercraft Liability Underlying Insurance Information (include any restrictions, extensions, waivers of subrogation, etc)Previous Experience (Give details of all liability claims exceeding $10,000 or occurrences that may give rise to claims, during the past 5 years)Care, Custody, ControlProperty Type Real Property Personal Property Value Of PropertySelect Which Best Applies (A) - Applicant is held harmless in the lease (B) - Applicant has a waiver of subrogation (C) - Applicant is a Named Insured in the Fire Policy Square Footage Of Building OccupiedOccupancy / Description of Personal PropertyVehicle InformationSelect Which Type(s) Of Vehicles Are Present Private Passenger Trucks : Light (up to 10,000 lbs GVW) Trucks : Medium (10,001 lbs to 21,000 lbs GVW) Trucks : Heavy (21,001 lbs to 45,000 lbs GVW) Trucks : Extra Heavy (over 45,000 lbs GVW) Truck/Tractors: Heavy (up to 45,000 lbs GCW) Truck/Tractors: Extra Heavy (over 45,000 lbs GCW) Buses Number Of Owned PPAsNumber Of Non-Owned PPAsNumber Of Leased PPAsPPA - Property Hauled (Write "None" if None) PPA - Radius (Miles) Local - 50 Miles Or Less Intermediate - 51 Mile to 200 Miles Long Distance - Over 200 Miles Number Of Owned Light TrucksNumber Of Non-Owned Light TrucksNumber Of Leased Light TrucksTrucks: Light - Property Hauled (Write "None" if None) Trucks: Light - Radius (Miles) Local - 50 Miles Or Less Intermediate - 51 Mile to 200 Miles Long Distance - Over 200 Miles Number of Owned Medium TrucksNumber of Non-Owned Medium TrucksNumber of Leased Medium TrucksTrucks: Medium - Property Hauled (Write "None" if None) Trucks: Medium - Radius (Miles) Local - 50 Miles Or Less Intermediate - 51 Mile to 200 Miles Long Distance - Over 200 Miles Number of Owned Heavy TrucksNumber of Non-Owned Heavy TrucksNumber of Leased Heavy TrucksTrucks: Heavy - Property Hauled (Write "None" if None) Trucks: Heavy - Radius (Miles) Local - 50 Miles Or Less Intermediate - 51 Mile to 200 Miles Long Distance - Over 200 Miles Number of Owned Extra Heavy TrucksNumber of Non-Owned Extra Heavy TrucksNumber of Leased Extra Heavy TrucksTrucks: Extra Heavy - Property Hauled (Write "None" if None) Trucks: Extra Heavy - Radius (Miles) Local - 50 Miles Or Less Intermediate - 51 Mile to 200 Miles Long Distance - Over 200 Miles Number of Owned Heavy Truck/TractorsNumber of Non-Owned Heavy Truck/TractorsNumber of Leased Heavy Truck/TractorsTruck/Tractor: Heavy - Property Hauled (Write "None" if None) Truck/Tractor: Heavy - Radius (Miles) Local - 50 Miles Or Less Intermediate - 51 Mile to 200 Miles Long Distance - Over 200 Miles Number of Owned Extra Heavy Truck/TractorsNumber of Non-Owned Extra Heavy Truck/TractorsNumber of Leased Extra Heavy Truck/TractorsTruck/Tractor: Extra Heavy - Property Hauled (Write "None" if None) Number of Owned BusesNumber of Non-Owned BusesNumber of Leased BusesTruck/Tractor: Extra Heavy - Property Hauled (Write "None" if None) Buses - Radius (Miles) Local - 50 Miles Or Less Intermediate - 51 Mile to 200 Miles Long Distance - Over 200 Miles ADDITIONAL EXPOSURE QUESTIONSAdvertisers Liability1. Media Used Put "NA" if not applicable1A. Annual Cost Of MediaPut "NA" if not applicable2. Are services of an advertising agency used? Yes No 3. Any coverage provided under Agency's Policy Yes No Aircraft Liability4. Does Applicant Own/Lease/Operate Aircraft? Yes No Auto Liability5. Are explosives, caustics, flammables or other dangerous cargo hauled? Yes No 6. Are passengers carried for a fee? Yes No 7. Any units not insured by underlying policies? Yes No 8. Are any vehicles leased or rented to others? Yes No 9. Are hired and non-owned coverages provided? Yes No Contractors Liability10. Is bridge, dam, or marine work performed? First Choice Second Choice Third Choice 11. Describe typical jobs performed (NA if not applicable)12. Describe any agreements (NA if not applicable)13. Does Applicant own, rent, or otherwise use cranes? Yes No 14. Do subcontractors carry coverages or limits less than applicant? Yes No Employers Liability15. Is applicant self-insured in any state? Yes No 16. Is applicant subjec to: (check all that apply) Jones Act FELA Stop Gap Other NONE Incidental Malpractice Liability17. Is a hospital or first aid facility maintained? Yes No 18. Are coverages provided for Doctors / Nurses Yes No 19. Indicate # of Doctors | # of Nurses | # of BedsPollution LiabilityEPA # (if applicable) 20. Do current or past products, or their components, contain hazardous materials that may require special disposal methods? Yes No 21. Indicate the current coverages carried NA GL with Standard ISO Pollution Exclusion GL with Standard Sudden & Accidental Only GL with Pollution Coverage Endorsement Separate Pollution Coverage Product Liability22. Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft? Yes No 23. Any Foreign operations, Foreign Products distributed in the USA or US Products Sold / Distributed in Foreign Countries? Yes No 24. Any Product Liability Loss(es) In The Past Three (3) Years? Yes No 25. Gross Sales from each of the last THREE (3) Years (NA is not applicable)Protective Liability26. Describe Independent Contractors In Your Business (NOT if not applicable)Watercraft Liability27. Does Applicant Own or Lease Watercraft Yes No List Location of | Owned or Lease | Length | Horsepower or ALL WatercraftApartments | Condominiums | Hotels | Motels28. Does Applicant own any apartments, condominiums, hotels, motels Yes No List Location(s) | # of Stories | # of Units | # of Swimming Pools | # of Diving Boards for all properties Δ
