North Carolina Division of Motor Vehicles
Eligible Risk Statement for Registration and Certificate of Title
I/we_____________________________________________________________ am/are an eligible risk for insurance coverage as defined in G.S. 58-37-
1(4a) because I am:
(Check at least one or more of the following that apply)
□1. A resident of North Carolina and have a valid driver license issued by the State of North Carolina.
□2. A resident of North Carolina who owns a motor vehicle registered or principally garaged in North Carolina. (“Principally garaged” means that the vehicle is garaged for six or more months of the current or preceding year on property in this State which is owned, leased, or otherwise lawfully occupied by you as the owner of the vehicle.)
□3. A person required to file proof of financial responsibility under Article 9A or 13 of Chapter 20 of the General Statutes in order to register a vehicle or to obtain a driver license in this State.
□4. A nonresident of this State and own a motor vehicle registered and principally garaged in North Carolina. (See Item 2 above for definition of “principally garaged”.)
□5. A nonresident of North Carolina and meet one of the following:
1)A member of the United States armed forces stationed in this State or deployed outside this State from a home base in this State who intends to return to his or her home state;
2)The spouse of a nonresident member of the United States armed forces stationed or deployed outside this State from a home base in this State who intends to return to his or her home state; or,
3)An out-of-state student who intends to return to his or her home state upon completion of his or her time as a student enrolled in school in this State; or
□6. The State of North Carolina and its agencies and cities, counties, towns, and municipal corporations in this State and their agencies.
I understand that providing incorrect or false and misleading information as to my status as an eligible risk can result in criminal prosecution and the denial of insurance coverage for any loss under any insurance policies for which application is made if I provide false and misleading information as to eligible risk status.
I will inform the insurer before the next policy renewal if I cease to be an “eligible risk” as defined in G.S. 58-37-1(4a).
Signature of owner(s)
Definition of Non-Fleet Private Passenger Vehicle as defined in G.S. 58-40-10
(Note, the vehicle must meet both definitions below to be a “non-fleet private passenger vehicle”)
“Private Passenger Motor Vehicle” means one of the following:
●A motor vehicle of the private passenger or station wagon type that is owned or hired under a long term contract to the insured and is not used for public transportation or rented to others.
●A pick up truck or van that is owned by an individual, or by a husband and wife, or individuals who are residents of the same household and has a gross vehicle weight (GVW) as specified by the manufacturer of less than 10,000 pounds and is not used for the delivery or transportation of goods or materials, unless the delivery or transportation of goods and material is:
(a)Incidental to the insured’s business of installing, maintaining, repairing furnishings or equipment; or
(b)For farming or ranching.
●A motorcycle, motorized scooter or other similar motorized vehicle not used for commercial purposes.
“Non-fleet” motor vehicle means:
A motor vehicle not eligible for classification as a fleet vehicle for the reason that the motor vehicle is one of four or fewer motor vehicles hired under a long-term contract or owned by the insured named in the policy.
Definition of “Eligible Risk” - “Eligible Risk” means that you may legally obtain automobile insurance for a “non-fleet private passenger motor vehicle in the state of North Carolina because at least one of the above classifications applies to you. It does not mean that you currently have automobile insurance.
IMPORTANT NOTE - YOU SHALL NOT BE DEEMED AN ELIGIBLE RISK if timely payment or premium is not tendered or if there is a valid unsatisfied judgment of record against you for recovery of amounts due for motor vehicle insurance premiums and you have not been discharged from paying the judgment or if you do not furnish the information necessary to effect insurance.