North Carolina Workers Compensation Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*Heather BaileyAJ BrowerCheyenne MathewsMichael ReeseEd JohnsonBill HeasleyJeff HallJared BellmundJack WingateINSURED INFORMATIONINSURED 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 PayrollINDIVIDUALS INCLUDED / EXCLUDEDNumber of Owners | Officers | Partners12345Owner | Officer | Partner 1 First Last Owner | Officer | Partner 1 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 1 - Title Owner | Officer | Partner 1 - Ownership % Owner | Officer | Partner 1 - Duties Owner | Officer | Partner 1 - Payroll | CompensationOwner | Officer | Partner 1 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 2 First Last Owner | Officer | Partner 2 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 2 - Title Owner | Officer | Partner 2 - Ownership % Owner | Officer | Partner 2 - Duties Owner | Officer | Partner 2 - Payroll | CompensationOwner | Officer | Partner 2 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 3 First Last Owner | Officer | Partner 3 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 3 - Title Owner | Officer | Partner 3 - Ownership % Owner | Officer | Partner 3 - Duties Owner | Officer | Partner 3 - Payroll | CompensationOwner | Officer | Partner 3 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 4 First Last Owner | Officer | Partner 4 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 4 - Title Owner | Officer | Partner 4 - Ownership % Owner | Officer | Partner 4 - Duties Owner | Officer | Partner 4 - Payroll | CompensationOwner | Officer | Partner 4 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 5 First Last Owner | Officer | Partner 5 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 5 - Title Owner | Officer | Partner 5 - Ownership % Owner | Officer | Partner 5 - Duties Owner | Officer | Partner 5 - Payroll | CompensationOwner | Officer | Partner 5 - Include | Exclude From CoverageExcludeIncludeGENERAL 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 ExplainWORKERS COMPENSATION GENERAL UNDERWRITINGDoes Applicant own, operate or lease aircraft / watercraft? No Yes Do / have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting or hazardous material? No Yes Any work performed underground or above 15 feet? No Yes Any work performed on barges, vessels, docks, bridges over water? No Yes Is applicant engaged in any other type of business? No Yes Are sub-contractors used? No Yes Give % of work subcontracted (and type)Any work sublet without Certificates of Insurance? No Yes Is there a written safety program in operation? No Yes Any group transportation provided? No Yes Any employees under 16 or over 60 years or age? No Yes Any seasonal employees? No Yes Is there any volunteer or donated labor? No Yes ExplainAny employees with physical handicaps? No Yes Do employees travel out of state? No Yes What States? How often?Are athletic teams sponsored? No Yes Are physicals required after offers or employment are made? No Yes Are employee health plans provided? No Yes Do any employees perform work for other businesses or subsidiaries? No Yes Do you lease employees to or from other employers? No Yes Do any employees predominately work at home? No Yes How Many? Any disputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? No Yes Please explain, including entity name(s) | carriers | policy numbersCARRIER SPECIFIC UNDERWRITING QUESTIONSDo any employees have any "out of state" exposure, outside of primary state? No Yes ExplainHas the Applicant or any partner, corporate officer, member or director ever been convicted or otherwise found guilty of a crime (Excluding offenses committed while a juvenile or sealed by court order)? No Yes ExplainAre employees exposed under U.S. Longshoremen's and Harborworkers' Act of the Federal Employee's Liability Act? No Yes Explain Δ
