Erie Insurance Business Auto Insurance Application QuestionsSelect Your Advisor*Jack WingateMichael ReeseJared BellmundAJ BrowerWilliam HeasleyINSURED INFORMATIONApplicant Name (Name of Business)Primary Contact First Last Mobile PhonePrimary Email Are Mailing & Location Address DifferentNoYesMailing Address 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 Location Address 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 Are there additional locations?NoYesList other locations (include full address)Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal IDNumber of years in businessNumber of EmployeesAnnual RevenueAnnual PayrollSelect Pay Plan*AnnualMonthly Draft/EFTOther (Prior Approval Needed)BUSINESS AUTO UNDERWRITINGAre All Vehicles Titled In Applicant's NameYesNoDoes this application insure all motor vehicles and trailers owned by Applicant?YesNoGive Year, Make, VIN of owned vehicles not to be insuredAre all vehicle(s) principally garaged at the business address?YesNoPlease give address for other garage locationsAre federal and/or state filings required?NoYesGive State(s) and docket number(s)Is Applicant required to comply with Motor Carrier Act of 1980 (MCS90)?NoYesAre vehicles leased to others?NoYesDescribe circumstances and submit copy of contracts?(DRIVER QUESTIONS) HAS ANY DRIVER...Had any auto insurance refused, cancelled or expired in the past 5 years or been excluded or restricted on a policy in past 5 years?NoYesGive Date(s) and reason(s)Been required to file evidence of financial responsibility in the past 5 years?NoYesGive Date(s) and reason(s)Had their driver's license revoked or suspended in past 5 years?NoYesList Driver(s) | Date(s) | Reason(s)Received a ticket for speeding, a PJC, or any other vehicle code violation within the past 5 years?NoYesGive Name(s) | Date(s) | Description of Violations (include speed & speed limit)Ever been arrested for ANY reason?NoYesGive Date(s) | Conviction(s) | Penalty(ies)Had a physical or mental impairment or disability or other medical infirmity?NoYesDescribeHad any comprehensive losses (deer, glass breakage, fire, theft, etc) in the past 5 years?NoYesDescribeWhile driving a motor vehicle, been involved in an accident or reported a claim to an insurance company during the past 5 years?NoYesDescribe all accidents regardless of who was at faultPlease Upload Any Relevant Documents You May Have Drop files here or This iframe contains the logic required to handle Ajax powered Gravity Forms. ShareFacebookTwitterLinkedInMorePinterestRedditEmailPrint
