Insured Name* First Last Mobile Phone*Email Who Is Your Erie Insurance Agent | AgencyInsurance CarrierErie InsuranceOtherPolicy NumberWhat Best Describes The Cause Of The Incident*My Property Was Damaged By Fire Or WaterMy Property Was Damaged By An Act Of NatureMy Property Was Lost Or Was Stolen In A Criminal ActMy Property Was Damaged By Another CauseSomeone Is Making A Claim Against Me (Liability Loss)Something Else HappenedWhat Caused The DamageFire Or SmokeWater From Sewer Or Drain BackupRupturing And/Or Leaking Of Plumbing PipesOther Water Damage Or MoldWhat Caused The DamageWindHailWeight Of Ice or SnowLightning or Power SurgeTree DebrisGround MovementWhat Caused The DamageTheftVandalismIdentity TheftWhat Caused The DamageFood SpoilageVehicleMechanical Or Electrical BreakdownExplosionCollapsePollution, Bio-Hazard, or Toxic MaterialsFalling ObjectsWhat Caused The DamageInjury To Others Or Damage To Their PropertyInjury Caused By An AnimalPersonal & Advertising Liability (Slander / Libel)Professional LiabilityLiquor LiabilityAssault Or BatteryApproximate Date Of Loss Approximate Time Of Loss : HH MM AMPM Where Did The Incident Occur? Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Damage Details (Enter At Least One)Home | DwellingOther StructuresPersonal PropertySomeone Else's PropertySomeone Else (Personal Injury)Where Did The Damage Occur? (Select All That Apply)ExteriorInteriorWhat Exterior Damage Occurred?RoofWindowsDoorsExterior WallsGuttersAC | FurnaceOtherHow Many Stories Are In The Home | Dwelling?123+What Interior Damage Occurred?CeilingFloorsWallsOtherHow Many Rooms Are Affected?1234+Is The Home | Building Safe To Live In?YesNoWhat Other Structures Were Damaged?Detached GarageShedFencePoolOtherPlease Provide Details About What Was DamagedPlease Provide Details About What Was DamagedDetails (Please Give Details As To What Happened) This iframe contains the logic required to handle Ajax powered Gravity Forms. ShareFacebookTwitterLinkedInGoogleMorePinterestRedditEmailPrint