Erie Insurance Business Auto Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*AJ BrowerJared BellmundHeather BaileyJack WingateMike ReeseBill HeasleyJeff HallEd JohnsonINSURED INFORMATIONApplicant Name (Name of Business)* Primary Contact* First Last Mobile Phone*Primary Email* Are Mailing & Location Address Different No Yes Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are there additional locations? No Yes List other locations (include full address)Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal ID Number of years in business Number of Employees Annual RevenueAnnual PayrollSelect Pay Plan*AnnualMonthly Draft/EFTOther (Prior Approval Needed)BUSINESS AUTO UNDERWRITINGAre All Vehicles Titled In Applicant's Name Yes No Does this application insure all motor vehicles and trailers owned by Applicant? Yes No Give Year, Make, VIN of owned vehicles not to be insuredAre all vehicle(s) principally garaged at the business address? Yes No Please give address for other garage locationsAre federal and/or state filings required? No Yes Give State(s) and docket number(s)Is Applicant required to comply with Motor Carrier Act of 1980 (MCS90)? No Yes Are vehicles leased to others? No Yes Describe 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? No Yes Give Date(s) and reason(s)Been required to file evidence of financial responsibility in the past 5 years? No Yes Give Date(s) and reason(s)Had their driver's license revoked or suspended in past 5 years? No Yes List Driver(s) | Date(s) | Reason(s)Received a ticket for speeding, a PJC, or any other vehicle code violation within the past 5 years? No Yes Give Name(s) | Date(s) | Description of Violations (include speed & speed limit)Ever been arrested for ANY reason? No Yes Give Date(s) | Conviction(s) | Penalty(ies)Had a physical or mental impairment or disability or other medical infirmity? No Yes DescribeHad any comprehensive losses (deer, glass breakage, fire, theft, etc) in the past 5 years? No Yes DescribeWhile driving a motor vehicle, been involved in an accident or reported a claim to an insurance company during the past 5 years? No Yes Describe all accidents regardless of who was at faultPlease Upload Any Relevant Documents You May Have Drop files here or Select files Max. file size: 60 MB. Δ
