Erie Insurance Commercial Account 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*
Pay Plan Selection*
What Types Of Insurance Are You Applying For?*
- Business Owners
- Business Auto Insurance
- Business Umbrella Insurance
- Workers Compensation Insurance
BUSINESS OWNERS INSURANCE SECTION
Check any/all of the exposures that apply (or that your ALLCHOICE Adivsor asked you to check)
Select The Primary Coverage(s)
- Liability Only
- Building
- Business Personal Property
- Equipment | Machinery
Select The Additional Coverage(s)
- None
- Employment Practices Liability (EPLI)
- Data Breach
- Pollution Liability Coverage
Do you have a Retail or Wholesale Exposure?
- Yes
- No
Check any/all of the Supplemental Exposures Below
- Habitational
- Contractor
- Manufacturing
Business Owners - Location | Building Information
Number of Buildings/Locations
Building 1 - Construction
Building 1 - Total Sqft
Building 1 - # of Stories
Building 1 - Year Built
Building 1 - Year Of Updates for Plumbing | Electric | HVAC | Roof (if none say none)
Building 1 - Protective Devices (check all that apply)
- Sprinklered - 100%
- Sprinklered - Less Than 100%
- Fire Alarm - Central Station
- Fire Alarm - Local (not monitored)
- Burglar Alarm - Central Station
- Burglar Alarm - Local (not monitored)
Building 2 - Construction
Building 2 - Total Sqft
Building 2 - # of Stories
Building 2 -Year Built
Building 2 - Year Of Updates for Plumbing | Electric | HVAC | Roof (if none say none)
Building 2 - Protective Devices (check all that apply)
- Sprinklered - 100%
- Sprinklered - Less Than 100%
- Fire Alarm - Central Station
- Fire Alarm - Local (not monitored)
- Burglar Alarm - Central Station
- Burglar Alarm - Local (not monitored)
Building 3 - Construction
Building 3 - Total Sqft
Building 3 - # of Stories
Building 3 - Year Built
Building 3 - Year Of Updates for Plumbing | Electric | HVAC | Roof (if none say none)
Building 3 - Protective Devices (check all that apply)
- Sprinklered - 100%
- Sprinklered - Less Than 100%
- Fire Alarm - Central Station
- Fire Alarm - Local (not monitored)
- Burglar Alarm - Central Station
- Burglar Alarm - Local (not monitored)
Business Owners - General Underwriting
Is this policy a rewrite of a current ERIE policy?
- No
- Yes
Give Policy Number
Are there any other premises or operations which are not to be covered by this insurance?
- No
- Yes
Explain
Has the Applicant ever failed to maintain liability or property insurance on this business during the past 5 years?
- No
- Yes
Previous Carrier
Explain
Has the Applicant ever been cancelled (including nonpay) or refused insurance of any kind by the ERIE or any other insurance carrier?
- No
- Yes
Explain
has the Applicant or any partner, corporate officer, member or director ever been convicted or otherwise found guilty of a crime (excluding offenses committed while a juvenile or sealed by court order)?
- No
- Yes
Explain (give date, place and reason for arrest. if convicted, give penalty)
Has the Applicant filed for bankruptcy in the past 5 years?
- No
- Yes
Explain
Any operations sold, acquired or discontinued in the last 5 years?
- No
- Yes
Explain
Is the Applicant involved in manufacturing, mixing, relabeling, or repackaging or products?
- No
- Yes
Explain
Does the Applicant sell or distribute foreign products not purchased from a US distributor?
- No
- Yes
Explain
Is there any commercial cooking (deep frying or grilling) in the building?
- No
- Yes
Explain
Retail % of Sales (if none write "$0")
Wholesale % of Sales (if none write "$0")
Internet Sales % of Sales (if none write "$0")
Installation/Service % of Sales (if none write "$0")
Business Owners - Claims Information
Has Applicant had any claims in the past 5 years (General Liability, Property, Etc)
- No
- Yes
Claim Info (Give Date, Approx Amount, Brief Explanation for all claims)
Business Owners - Supplemental Underwriting - Habitational
Do ALL buildings have two separate exits from each unit?
- Yes
- No
Describe the means of egress from the building(s)
Do ALL buildings have hardwired smoke detectors with battery backup OR smoke detectors with long life lithium batteries installed in every unit?
- Yes
- No
Do ALL buildings have a fire alarm system?
- Yes
- No
Do ALL buildings have carbon monoxide detectors installed in all units that have gas appliances or fireplaces?
- Yes
- No
Do ALL buildings have multi-purpose fire extinguishers available in all hallways and common areas?
- Yes
- No
Do ALL buildings have emergency lighting installed in all common areas?
- Yes
- No
- No Common Areas
Do ALL buildings require written, 12 month leases (or greater)?
- Yes
- No
Please describe lease
Do ALL buildings have a lease agreement requiring tenants to carry their own insurance with certificates provided to the building owner?
- Yes
- No
Explain
Do ALL buildings have an occupancy rate of 80% or higher?
- Yes
- No
Provide Actual Occupancy Rate
Do ANY buildings all grilling or other outdoor fires within 10 feet of any structure?
- No
- Yes
Explain
Do ANY buildings contain student housing, assisted living, or seasonal/timeshare occupancies?
- No
- Yes
Explain
Do ANY buildings have recreational facilities, such as swimming pools, exercise equipment, playground, tennis court, dock/boat slips, etc?
- No
- Yes
Describe recreational facilities present
Do ANY buildings have a lake, pond or reservoir on premises?
- No
- Yes
Please describe, including size and depth
Business Owners - Supplemental Underwriting - Data Breach
Data Breach Response Expenses - Increased Coverage Limit
Data Breach Liability
How many customers/employees/patients/clients/tenants' information do you have on file?
Please check (all that apply) which of the following types of data you collect, store, manage or process containing the following Personally Identifiable Information, Payment Card Information, or Health Information
- Social Security Numbers
- Banking / Financial Information
- Credit Cards / Debit Cards / Other Payment Cards
- Health Information & Medical Records
- None
Please check (all that apply) the computer security controls that are currently in place
- Anti-Virus Software
- Password Protected computers, laptops, and other mobile devices
- Secured wireless connectivity for laptops and other mobile devices
- Firewall
- Data stored on laptops, back-up tapes, or other portable media is encrypted
- None
Have you suffered a breach of personal information, including loss or theft of laptops, smart phones, etc?
- No
- Yes
Explain
Do you conduct annual training for employees concerning data security and the handling of personal information?
- Yes
- No
Do you post and circulate your document retention and destruction policy to your employees?
- Yes
- No
Business Owners - Supplemental Underwriting - EPLI
Aggregate Limit Amount
Deductible
# Of Full Time Employees
# Of Part Time Employees
Retro-Active Date (If Current EPLI Coverage In Force)
Month
Day
Year
Has the Applicant filed for bankruptcy within the past 5 years?
- No
- Yes
What percentage of employees are salaried?
What percentage of employees are non-salaried?
What percentage of employees are union?
What percentage of employees have wages <$50,000
What percentage of employees have wages $50,000-$100,000
What percentage of employees have wages >$100,000
Employee Turnover Summary - Voluntary
Give % Of Voluntary Employee Turnover (Employee Chooses To Leave) for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 Months
Employee Turnover Summary - Involuntary
Give % Of Involuntary Employee Turnover (Employee Is Terminated (non layoff)) for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 Months
Employee Turnover Summary - Layoff
Give % Of Layoff Employee Turnover for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 Months
Employee Turnover Summary - Other
Give % Of Other (if doesn't fit above circumstances) Employee Turnover for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 Months
Are there any staff reductions and/or mergers and acquisitions planned within the next 12 months?
- Yes
- No
Is there a dedicated Human Resource Department/Function?
- Yes
- No
Does Applicant post all notices required by law?
- Yes
- No
Are signed/dated employment applications required for all prospective employees?
- Yes
- No
Does the Applicant utilize an employment handbook, website, or written employment materials (such as anti-harassment or anti-discrimination policies) to advise employees of their rights to work free of harassment and discrimination in the workplace?
- Yes
- No
Does the Applicant have a written procedure for reporting and investigating any harassment or discrimination in the workplace?
- Yes
- No
Do all employees have written performance evaluations?
- Yes
- No
Has the Applicant or any executive, officer, or owner been involved in any claim, potential claim, insurance loss, lawsuit, administrative or criminal proceeding, investigation or inquiry, arising in whole or in part out of Employment Practices Liability Claims within the last five years?
- Yes
- No
Does the Applicant know of any incidents that may give rise to an insurance claim, lawsuit, administrative or criminal proceeding, investigation or inquiry, against the Applicant or any executive, officer or owner?
- Yes
- No
Has the Applicant ever had an application for Employment Practices Liability Coverage declined or have you ever had an Employment Practices Liability policy cancelled or non-renewed?
- Yes
- No
Business Owners - Supplemental Underwriting - Pollution
Description of pollutant type(s)
Quantity Stored Of Each Pollutant Type
Specify the type and quantity if more than 1 Pollutant Type
Quantity Stored At Job Of Each Pollutant Type
Specify the type and quantity if more than 1 Pollutant Type
Description of where and how pollutants are stored (on and off premises)
Specify the type and quantity if more than 1 Pollutant Type
BUSINESS AUTO INSURANCE SECTION
Is this policy a rewrite of a current ERIE policy?
- No
- Yes
Give Policy Number
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?
Business Auto - (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
COMMERCIAL UMBRELLA INSURANCE SECTION
Is policy a rewrite of a current Erie Policy
- No
- Yes
Policy Number
Does the applicant own, lease or charter any aircraft or watercraft?
- No
- Yes
Describe
Do underlying insurance policies cover these exposures?
- Yes
- No
Are there any operations not covered by the schedule of underlying policies?
- No
- Yes
Explain
Has the applicant had any general liability or auto liability claims greater than $250,000 in the past 5 years
- No
- Yes
Give Claim Detail
1. Include Claim Date(s) 2. Include Claim Type 3. Is the Claim Open Or Closed 4. Total Amount Paid 5. Total Amount Still Reserved (if claim is still open)
WORKERS COMPENSATION INSURANCE SECTION
If you have any "Contracting" Exposure Check "YES"
- Yes
- No
If in doubt, check "YES"
Workers Compensation - Include/Exclude Section
Number of Owners | Officers | Partners
Owner | Officer | Partner 1
First Last
Owner | Officer | Partner 1 - Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 1 - Title
Owner | Officer | Partner 1 - Ownership %
Owner | Officer | Partner 1 - Duties
Owner | Officer | Partner 1 - Payroll | Compensation
Owner | Officer | Partner 1 - Include | Exclude From Coverage
Owner | Officer | Partner 2
First Last
Owner | Officer | Partner 2 - Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 2 - Title
Owner | Officer | Partner 2 - Ownership %
Owner | Officer | Partner 2 - Duties
Owner | Officer | Partner 2 - Payroll | Compensation
Owner | Officer | Partner 2 - Include | Exclude From Coverage
Owner | Officer | Partner 3
First Last
Owner | Officer | Partner 3 - Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 3 - Title
Owner | Officer | Partner 3 - Ownership %
Owner | Officer | Partner 3 - Duties
Owner | Officer | Partner 3 - Payroll | Compensation
Owner | Officer | Partner 3 - Include | Exclude From Coverage
Owner | Officer | Partner 4
First Last
Owner | Officer | Partner 4 - Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 4 - Title
Owner | Officer | Partner 4 - Ownership %
Owner | Officer | Partner 4 - Duties
Owner | Officer | Partner 4 - Payroll | Compensation
Owner | Officer | Partner 4 - Include | Exclude From Coverage
Owner | Officer | Partner 5
First Last
Owner | Officer | Partner 5 - Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 5 - Title
Owner | Officer | Partner 5 - Ownership %
Owner | Officer | Partner 5 - Duties
Owner | Officer | Partner 5 - Payroll | Compensation
Owner | Officer | Partner 5 - Include | Exclude From Coverage
Workers Compensation - General Underwriting
Total Number Of Workers' Comp Claims in the past 5 years?
Does Applicant have any vehicles titled to the business?
- Yes
- No
Is this policy a rewrite of a current ERIE policy?
- No
- Yes
Give Policy Number
Do any employees have any "out of state" exposure, outside of primary state?
- No
- Yes
Explain
Has the Applicant or any partner, corporate officer, member or director ever been convicted or otherwise found guilty of a crime (Excluding offenses committed while a juvenile or sealed by court order)?
- No
- Yes
Explain
Has the Applicant filed for bankruptcy in the past 5 years?
- No
- Yes
Explain
Do employees or Applicant own or operate any aircraft or watercraft?
- No
- Yes
Explain
Are employees exposed under U.S. Longshoremen's and Harborworkers' Act of the Federal Employee's Liability Act?
- No
- Yes
Explain
Is there any donated labor
- No
- Yes
Workers Compensation - Contractors Supplemental
Does the organization have a formal accident investigation procedure in place?
- Yes
- No
Has the organization had any OSHA citations in the last 5 years?
- Yes
- No
Does the organization offer an Early Return-to-Work/Light/Duty Program?
- Yes
- No
In the past two (2) years, what percentage of the organization's work has been Residential?
Does the organization perform any of the operations below? (Check all that apply)
- Tree Trimming
- Iron Steel Erection
- EIFS (Exterior Insulation & Finish Systems)
- Roofing
- Blasting Demolition
- Hazardous Material Handling
- Asbestos Removal
- Lead Abatement
- Mold Remediation
- Fire Restoration
- Hire Subcontractors
In the past two (2) years, what percentage of the organization's work has been Commercial?
Describe the type of work you performed within the past 5 years and/or five jobs
Does the organization perform ANY work 6 feet or higher?
- No
- Yes
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ALLCHOICE Agent Information

INSURED INFORMATION

BUSINESS OWNERS INSURANCE SECTION

Business Owners - Location | Building Information

Business Owners - General Underwriting

Business Owners - Claims Information

Business Owners - Supplemental Underwriting - Habitational

Business Owners - Supplemental Underwriting - Data Breach

Business Owners - Supplemental Underwriting - EPLI

Business Owners - Supplemental Underwriting - Pollution

BUSINESS AUTO INSURANCE SECTION

Business Auto - (Driver Questions) - Has Any Driver...

COMMERCIAL UMBRELLA INSURANCE SECTION

WORKERS COMPENSATION INSURANCE SECTION

Workers Compensation - Include/Exclude Section

Workers Compensation - General Underwriting

Workers Compensation - Contractors Supplemental