North Carolina Homeowners Auto Umbrella Insurance Application QuestionsName First Last Mobile PhoneEmail 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 RefusedExplanationEver been arrested for ANY reason?YesNoExplanationOf driving age had a physical or mental impairment or disability or other medical infirmity?YesNoExplanationHad an accident, claim, loss, moving violation, or driver license suspension/revocation in the past 5 years?YesNoExplanationAre all vehicles solely titled to (or leased to) a Named Insured?YesNo(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?YesNoExplanationDoes any driver or member of the household use a vehicle(s) for one of the following: Delivery | Sales | Services | Transporting Goods/EquipmentYesNoExplanationAre listed drivers residents of NC?YesNoExplanationHOME INSURANCE QUESTIONSIs the dwelling at the indicated property currently owned and occupied as your primary residence?YesNoExplainHave you ever had similar insurance on this property or any other property during the past 5 years?YesNoWhich Company(ies)EXCEPT for non-payment of premium, has any company declined, cancelled, or refused to renew similar insurance?YesNoExplainHave 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?YesNoExplain (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?YesNoExplain - Include how often cleaned, and date last cleanedIs there a swimming pool on the premises?YesNoAbove Ground? Inground? Pool Enclosed By Fence?Are there animals, including farm animals or pets on the premises?YesNoProvide Animal Type(s) (If Dog include breed)Is the applicant conducting any business or occupational pursuits at the premises?YesNoExplainDate 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 QUESTIONSDoes applicant own any residences such as seasonal, rented to others, or vacant properties which have not previously been identified in the applications?YesNoPlease provide address, # of families, OccupancyDoes applicant own, lease, or have regularly furnished to them any motorized vehicles or recreational vehicles which have not previously been identified in this application?YesNoPlease provide year, make, model & explanationAre any of the vehicles listed on underlying policies used for commercial use?YesNoHas 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?YesNoExplainHas 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?YesNoExplainHas Applicant had any primary or excess liability insurance cancelled or denied in the past 5 years?YesNoExplainDoes applicant have a business exposure in the residence premises?YesNoExplainDoes applicant own, lease, or have furnished for their regular use any watercraft which has not previously been identified in this application?YesNoExplainHas 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?YesNoExplainAre there animals, including farm animals or pets, on the premises that have not been disclosed already?YesNoExplain This iframe contains the logic required to handle Ajax powered Gravity Forms. ShareFacebookTwitterLinkedInMorePinterestRedditEmailPrint
