North Carolina Homeowners Auto Umbrella Insurance Application Questions

ALLCHOICE Agent Information

Select Your Advisor*

INSURED INFORMATION

Name*

First Last

Address*

Street Address City State ZIP Code

Mobile Phone*

Email*

AUTO INSURANCE QUESTIONS

Has 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

Explanation

Ever been arrested for ANY reason?

Yes
No

Explanation

Of driving age had a physical or mental impairment or disability or other medical infirmity?

Yes
No

Explanation

Had an accident, claim, loss, moving violation, or driver license suspension/revocation in the past 5 years?

Yes
No

Explanation

Are all vehicles solely titled to (or leased to) a Named Insured?

Yes
No

(First Named Insured, Spouse, or Domestic Partner on this policy)

Explanation

Are there additional vehicles owned by a Named Insured which are not insured at this time, or are insured elsewhere?

Yes
No

Explanation

Does any driver or member of the household use a vehicle(s) for one of the following: Delivery | Sales | Services | Transporting Goods/Equipment

Yes
No

Explanation

Are listed drivers residents of NC?

Yes
No

Explanation

HOME INSURANCE QUESTIONS

Is the dwelling at the indicated property currently owned and occupied as your primary residence?

Yes
No

Explain

Have 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

Explain

Have 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 Information

1. Manufacturer Of Wood Stove 2. How Often Is Wood Stove Cleaned 3. Date Of The Last Cleaning

Is 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

Explain

Date 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")

UMBRELLA INSURANCE QUESTIONS

Does applicant own any residences such as seasonal, rented to others, or vacant properties which have not previously been identified in the applications?

Yes
No

Please provide address, # of families, Occupancy

Does applicant own, lease, or have regularly furnished to them any motorized vehicles or recreational vehicles which have not previously been identified in this application?

Yes
No

Please provide year, make, model & explanation

Are any of the vehicles listed on underlying policies used for commercial use?

Yes
No

Has any driver or member of the household had a moving violation or driver license suspension/revocation in the last 5 years which has not been discussed with ALLCHOICE?

Yes
No

Explain

Has any driver or member of the household, while driving a motor vehicle, been involved in an accident or reported a claim to an insurance company during the past 5 years which has not been discussed with ALLCHOICE?

Yes
No

Explain

Has Applicant had any primary or excess liability insurance cancelled or denied in the past 5 years?

Yes
No

Explain

Does applicant have a business exposure in the residence premises?

Yes
No

Explain

Does applicant own, lease, or have furnished for their regular use any watercraft which has not previously been identified in this application?

Yes
No

Explain

Has the applicant had any personal liability or auto liability losses paid or reserved greater than $5,000 in the past 5 years that has not been discussed with ALLCHOICE?

Yes
No

Explain

Are there animals, including farm animals or pets, on the premises that have not been disclosed already?

Yes
No

Explain