Insurance Application Questions – Personal Lines – Multi Policy

ALLCHOICE Agent Information
Select Your Advisor(Required)
WE NEED YOUR INFORMATION
Name(Required)
First Last
Address(Required)
Street Address City 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
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
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

Insurance Application Questions – Personal Lines – Multi Policy

Insurance Application Questions – Personal Lines – Multi Policy

ALLCHOICE Agent Information

WE NEED YOUR INFORMATION

AUTO INSURANCE UNDERWRITING QUESTIONS

Has any driver or member of the household:

HOME INSURANCE QUESTIONS

RENTERS INSURANCE QUESTIONS

UMBRELLA INSURANCE QUESTIONS