North Carolina Homeowners & Auto Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*Heather BaileyAJ BrowerCheyenne MathewsMichael ReeseEd JohnsonBill HeasleyJeff HallJared BellmundJack WingateINSURED INFORMATIONName* First Last 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 Mobile Phone*Email* AUTO INSURANCE QUESTIONSHas any driver or member of the household:Ever had any of the following occur regarding their auto insurance in the past 5 years? Driver Excluded On Policy Insurance Cancelled Insurance Expired Insurance Refused ExplanationEver been arrested for ANY reason? Yes No ExplanationOf driving age had a physical or mental impairment or disability or other medical infirmity? Yes No ExplanationHad an accident, claim, loss, moving violation, or driver license suspension/revocation in the past 5 years? Yes No ExplanationAre all vehicles solely titled to (or leased to) a Named Insured? Yes No (First Named Insured, Spouse, or Domestic Partner on this policy)ExplanationAre there additional vehicles owned by a Named Insured which are not insured at this time, or are insured elsewhere? Yes No ExplanationDoes any driver or member of the household use a vehicle(s) for one of the following: Delivery | Sales | Services | Transporting Goods/Equipment Yes No ExplanationAre listed drivers residents of NC? Yes No ExplanationHOME INSURANCE QUESTIONSIs the dwelling at the indicated property currently owned and occupied as your primary residence? Yes No ExplainHave you ever had similar insurance on this property or any other property during the past 5 years? Yes No Which Company(ies)EXCEPT for non-payment of premium, has any company declined, cancelled, or refused to renew similar insurance? Yes No ExplainHave you had any losses or claims of any nature, whether insured or not, such as fire, windstorm, theft, liability, etc. on this or any other property during the last 5 years? Yes No Explain (Year, Approx Cost, Cause)When was the property purchased (MM/YYYY) Are there any wood burning stoves, wood burning fireplace inserts, wood burning furnaces, space heaters, or kerosene heaters on the premises? Yes No Required Information1. Manufacturer Of Wood Stove 2. How Often Is Wood Stove Cleaned 3. Date Of The Last CleaningIs there a swimming pool on the premises? Yes No Above Ground? Inground? Pool Enclosed By Fence?Are there animals, including farm animals or pets on the premises? Yes No Provide Animal Type(s) (If Dog include breed)Is the applicant conducting any business or occupational pursuits at the premises? Yes No ExplainDate of Last Roof Update (if none write "NONE") Date of Last Electrical Update (if none write "NONE") Date of Last Plumbing Update (if none write "NONE") Date of Last HVAC Update (if none write "NONE") Δ
