Erie Insurance Business Auto Insurance Application Questions

ALLCHOICE Agent Information

Select Your Advisor*

INSURED INFORMATION

Applicant Name (Name of Business)*

Primary Contact*

First Last

Mobile Phone*

Primary Email*

Are Mailing & Location Address Different

No
Yes

Mailing Address

Street Address City State ZIP Code

Location Address

Street Address City State ZIP Code

Are there additional locations?

No
Yes

List other locations (include full address)

Legal Entity Type

Tax | Federal ID

Number of years in business

Number of Employees

Annual Revenue

Annual Payroll

Select Pay Plan*

BUSINESS AUTO UNDERWRITING

Are 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 insured

Are all vehicle(s) principally garaged at the business address?

Yes
No

Please give address for other garage locations

Are 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

Describe

Had any comprehensive losses (deer, glass breakage, fire, theft, etc) in the past 5 years?

No
Yes

Describe

While 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 fault

Please Upload Any Relevant Documents You May Have

Drop files here or