ALLCHOICE Insurance
Insurance Application Questions – Personal Lines – Multi Policy
Insurance Application Questions – Personal Lines – Multi Policy
ALLCHOICE Agent Information
Select Your Advisor
(Required)
Cheyenne Mathews
Sara Surigao
John Surigao
Heather Bailey
AJ Brower
Michael Reese
Ed Johnson
Bill Heasley
Jeff Hall
Jared Bellmund
WE NEED YOUR INFORMATION
Name
(Required)
First
Last
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mobile Phone
(Required)
Is It Ok For Us To Text You?
(Required)
Yes
No
Email
(Required)
Please Select The Type(s) Of Insurance You Need
(Required)
Auto Insurance
Homeowners Insurance
Renters Insurance
Personal Umbrella
AUTO INSURANCE UNDERWRITING 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?
(Required)
No
Driver Excluded On Policy
Insurance Cancelled
Insurance Expired
Insurance Refused
Explanation
Ever been arrested for ANY reason?
(Required)
Yes
No
Explanation
Of driving age had a physical or mental impairment or disability or other medical infirmity?
(Required)
Yes
No
Explanation
Had an accident, claim, loss, moving violation, or driver license suspension/revocation in the past 5 years?
(Required)
Yes
No
Explanation
Are all vehicles solely titled to (or leased to) a Named Insured?
(Required)
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?
(Required)
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
(Required)
Yes
No
Explanation
Are listed drivers residents of NC?
(Required)
Yes
No
Explanation
NC Law Requires That We Verify Your Residency (Please Choose Two)
(Required)
Valid Drivers License
Military ID
Valid Vehicle Registration
Utility Bill
Tax Return
Would You Like To Upload Proof Of Residency Now?
(Required)
Yes
No
Please Upload Your Proof Of Residency
(Required)
Drop files here or
Select files
Max. file size: 12 GB.
Acceptable Proof Of Residency: 1. Drivers License 2. Passport 3. Utility Bill 4. Tax Bill 5. Tax Return
HOME INSURANCE QUESTIONS
Include Orion180 Verification Statements?
(Required)
I’m Not Sure
Yes
No
Is the dwelling at the indicated property currently owned and occupied as your primary residence?
(Required)
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
Is Your Home Older Than 10 Years?
(Required)
No
Yes
Have There Been Any Updates To The Following?
(Required)
Roof
Heating & Air Systems (HVAC)
Plumbing
Electrical
Hot Water Heater
Select All That Apply
Date of Last Roof Replaced
(Required)
Date of Last HVAC Update
(Required)
Date of Last Plumbing Update
(Required)
Date of Last Electrical Update
(Required)
Date Hot Water Heater Replaced
(Required)
Insurance Carriers Require Two CURRENT Pictures Of Your Home (Front & Back). Have you sent your Agent these Pictures yet?
(Required)
Yes
No
Please Upload Photos Of Your Home
Drop files here or
Select files
Max. file size: 12 GB.
We need photos of the FRONT & BACK of your home
This home’s primary heating is a thermostatically controlled central heating or electric heating system. I understand that if a converted coal furnace, kerosene heater, electric space heater, or wood/coal/pellet stove is the primary source of heat, the home is not eligible for this policy.
(Required)
True
False
This home does not have knob and tube wiring, fuses, aluminum wiring, an electrical system that does not meet current building code or a Federal Pacific electrical panel.
(Required)
True
False
This home is not constructed with EIFS (Exterior Insulation and Finish System), asbestos, wood shake, Masonite or Dryvit stucco materials.
(Required)
True
False
No portion of this home is built over water.
(Required)
True
False
This home was not constructed prior to 1900.
(Required)
True
False
If this home has a swimming pool, it does not have a pool slide nor diving board, and it has a minimum four-foot fence enclosure around the pool.
(Required)
True
False
This home does not have a Trampoline
(Required)
True
False
No business activity is conducted on the premises including but not limited to farming, daycare, or childcare
(Required)
True
False
This home is equipped with circuit breakers.
(Required)
True
False
This home is not a rental home or used for any rental purpose. I understand the policy does not provide coverage for rental home exposures
(Required)
True
False
If this is not a seasonal or secondary home, this home is not vacant or unoccupied for more than sixty (60) consecutive days
(Required)
True
False
This home was constructed by a licensed contractor and is not a Do-It-Yourself, Dome, Shell or home using unconventional parts or not meeting building codes.
(Required)
True
False
This dwelling is not occupied by more than one family OR by roomers or boarders for longer than 30 consecutive days
(Required)
True
False
There are no more than two mortgages on this home.
(Required)
True
False
This home is not for sale or in foreclosure.
(Required)
True
False
If this is a seasonal or secondary home, it is regularly overseen by a reputable party living within fifty (50) miles of the residence when it is unoccupied
(Required)
True
False
During the last 5 years, applicant(s) have not been indicted for or convicted of any degree of crime of Fraud, Bribery, Arson, or any other arson related crime.
(Required)
True
False
This home is situated on no more than 5 acres of land, unless in a Planned Community and on no more than 10 acres
(Required)
True
False
This property is not in the course of construction, has no existing damage, and is not in a state of disrepair.
(Required)
True
False
I do not have any of the following pure or mixed breeds of dogs: Terriers (including but not limited to Pit Bull or Staffordshire Terrier breeds), Dobermans, Rottweilers, Chow Chows, Presa Carios, or Wolf Hybrids
(Required)
True
False
I do not have any animals in my house that have a bite or attack history.
(Required)
True
False
This home does not have galvanized, cast iron, pre-2006 PEX Plumbing, nor polybutylene plumbing.
(Required)
True
False
This home is not on a historic registry or located in a designated historic district
(Required)
True
False
RENTERS INSURANCE QUESTIONS
Does The Applicant desire Water Backup or Sump Overflow Coverage?
(Required)
No
Yes
Is the dwelling at the indicated property currently owned and occupied as your primary residence?
(Required)
Yes
No
Explain
Have you ever had similar insurance on this property or any other property during the past 5 years?
(Required)
Yes
No
Which Company(ies)
EXCEPT for non-payment of premium, has any company declined, cancelled, or refused to renew similar insurance?
(Required)
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?
(Required)
Yes
No
Explain (Year, Approx Cost, Cause)
Are there animals, including farm animals or pets on the premises?
(Required)
Yes
No
Provide Animal Type(s) (If Dog include breed) (are any animals dangerous or show propensity to bite)
Is the applicant conducting any business or occupational pursuits at the premises?
(Required)
Yes
No
Explain
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?
(Required)
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?
(Required)
Yes
No
Please provide year, make, model & explanation
Are any of the vehicles listed on underlying policies used for commercial use?
(Required)
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?
(Required)
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?
(Required)
Yes
No
Explain
Has Applicant had any primary or excess liability insurance cancelled or denied in the past 5 years?
(Required)
Yes
No
Explain
Does applicant have a business exposure in the residence premises?
(Required)
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?
(Required)
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?
(Required)
Yes
No
Explain
Are there animals, including farm animals or pets, on the premises that have not been disclosed already?
(Required)
Yes
No
Explain
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