North Carolina Business Umbrella Insurance Application QuestionsINSURED 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 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 UMBRELLA UNDERWRITINGUnderlying InsuranceUnderlying Insurance NOT with ALLCHOICE Automobile Liability General Liability Workers CompensationAUTOB Carrier | Policy NumberAUTOB Effective Date MM DD YYYYAUTOB Liability Limit$1,000,000 CSL$750,000 CSL$500,000 CSL$300,000 CSL< $300,000 CSLAUTOB Annual PremiumCGL Carrier | Policy NumberCGL Effective Date MM DD YYYYCGL 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 OccCGL Annual PremiumWORK Carrier | Policy NumberWORK Effective Date MM DD YYYYWORK Liability Limit$1M | $1M | $1M$500K | $500K | $500K$100K | $500K | $100KWORK Annual PremiumDo You Have Employee Benefits Liability CoverageNoYesName Of Benefit ProgramLimit Of Insurance (Ea Employee)Aggregate Limit For EBLRetained Limit For EBLRetroactive Date For EBL MM DD YYYY1. Are Defense Costs:Within Aggregate Limits?A Separate Limit?Unlimited?I don't know2. Indicate the Edition Date of the ISO form or similar filing for the underlying coverageIf you don't know - Mark "NA"3. Has any product, work, accident or location been excluded, uninsured or self-insured from any previous coverage?NoYes4. For CLAIMS MADE, indicate Retroactive Date of current underlying policy: (leave blank if not Claims Made) Date Format: MM slash DD slash YYYY 5. For CLAIMS MADE, indicate entry date into uninterrupted Claims Made Coverage: (leave blank if not claims made) MM DD YYYY6. For CLAIMS MADE, was "TAIL" coverage purchased for any previous primary or excess policy?NAYesNoEffective Date Of Tail Coverage MM DD YYYYCoverage & Exposure (Check coverage in underlying policies & also check if any exposure)Check If Appropriate \ Coverage Exists Auto Liability CGL - Claims Made CGL - OccurrenceCheck 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 LiabilityUnderlying 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 TypeReal PropertyPersonal PropertyValue 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 PolicySquare 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) BusesNumber Of Owned PPAsNumber Of Non-Owned PPAsNumber Of Leased PPAsPPA - Property Hauled (Write "None" if None)PPA - Radius (Miles)Local - 50 Miles Or LessIntermediate - 51 Mile to 200 MilesLong Distance - Over 200 MilesNumber 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 LessIntermediate - 51 Mile to 200 MilesLong Distance - Over 200 MilesNumber 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 LessIntermediate - 51 Mile to 200 MilesLong Distance - Over 200 MilesNumber 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 LessIntermediate - 51 Mile to 200 MilesLong Distance - Over 200 MilesNumber 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 LessIntermediate - 51 Mile to 200 MilesLong Distance - Over 200 MilesNumber 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 LessIntermediate - 51 Mile to 200 MilesLong Distance - Over 200 MilesNumber 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 LessIntermediate - 51 Mile to 200 MilesLong Distance - Over 200 MilesADDITIONAL EXPOSURE QUESTIONSAdvertisers Liability1. Media UsedPut "NA" if not applicable1A. Annual Cost Of MediaPut "NA" if not applicable2. Are services of an advertising agency used?YesNo3. Any coverage provided under Agency's PolicyYesNoAircraft Liability4. Does Applicant Own/Lease/Operate Aircraft?YesNoAuto Liability5. Are explosives, caustics, flammables or other dangerous cargo hauled?YesNo6. Are passengers carried for a fee?YesNo7. Any units not insured by underlying policies?YesNo8. Are any vehicles leased or rented to others?YesNo9. Are hired and non-owned coverages provided?YesNoContractors Liability10. Is bridge, dam, or marine work performed?First ChoiceSecond ChoiceThird Choice11. 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?YesNo14. Do subcontractors carry coverages or limits less than applicant?YesNoEmployers Liability15. Is applicant self-insured in any state?YesNo16. Is applicant subjec to: (check all that apply) Jones Act FELA Stop Gap Other NONEIncidental Malpractice Liability17. Is a hospital or first aid facility maintained?YesNo18. Are coverages provided for Doctors / NursesYesNo19. 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?YesNo21. 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 CoverageProduct Liability22. Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft?YesNo23. Any Foreign operations, Foreign Products distributed in the USA or US Products Sold / Distributed in Foreign Countries?YesNo24. Any Product Liability Loss(es) In The Past Three (3) Years?YesNo25. 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 WatercraftYesNoList Location of | Owned or Lease | Length | Horsepower or ALL WatercraftApartments | Condominiums | Hotels | Motels28. Does Applicant own any apartments, condominiums, hotels, motelsYesNoList Location(s) | # of Stories | # of Units | # of Swimming Pools | # of Diving Boards for all properties This iframe contains the logic required to handle Ajax powered Gravity Forms. ShareFacebookTwitterLinkedInMorePinterestRedditEmailPrint
