Erie Insurance Commercial Account 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 Type*CorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal ID* Number of years in business* Number of Employees* Annual Revenue*Annual Payroll*Pay Plan Selection*AnnualMonthly Draft/EFTOther (Prior Approval Needed)What Types Of Insurance Are You Applying For?* Business Owners Business Auto Insurance Business Umbrella Insurance Workers Compensation Insurance BUSINESS OWNERS INSURANCE SECTIONCheck 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 InformationNumber of Buildings/Locations123Building 1 - ConstructionFrameBrick/Masonry VeneerJoisted Masonry (walls are block with frame roof)Masonry Non Combustible (black with non-wood roof)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 - ConstructionFrameBrick/Masonry VeneerJoisted Masonry (walls are block with frame roof)Masonry Non Combustible (black with non-wood roof)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 - ConstructionFrameBrick/Masonry VeneerJoisted Masonry (walls are block with frame roof)Masonry Non Combustible (black with non-wood roof)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 UnderwritingIs 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 ExplainHas the Applicant ever failed to maintain liability or property insurance on this business during the past 5 years? No Yes Previous Carrier ExplainHas the Applicant ever been cancelled (including nonpay) or refused insurance of any kind by the ERIE or any other insurance carrier? No Yes Explainhas 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 ExplainAny operations sold, acquired or discontinued in the last 5 years? No Yes ExplainIs the Applicant involved in manufacturing, mixing, relabeling, or repackaging or products? No Yes ExplainDoes the Applicant sell or distribute foreign products not purchased from a US distributor? No Yes ExplainIs there any commercial cooking (deep frying or grilling) in the building? No Yes ExplainRetail % 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 InformationHas 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 - HabitationalDo 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 leaseDo ALL buildings have a lease agreement requiring tenants to carry their own insurance with certificates provided to the building owner? Yes No ExplainDo 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 ExplainDo ANY buildings contain student housing, assisted living, or seasonal/timeshare occupancies? No Yes ExplainDo ANY buildings have recreational facilities, such as swimming pools, exercise equipment, playground, tennis court, dock/boat slips, etc? No Yes Describe recreational facilities presentDo ANY buildings have a lake, pond or reservoir on premises? No Yes Please describe, including size and depthBusiness Owners - Supplemental Underwriting - Data BreachData Breach Response Expenses - Increased Coverage Limit$10,000$25,000$50,000$100,000$250,000$500,000$1,000,000Data Breach Liability$10,000$25,000$50,000$100,000$250,000$500,000$1,000,000How many customers/employees/patients/clients/tenants' information do you have on file?1 to 9,99910,000 to 24,99925,000 to 49,99950,000 to 149,999150,000 to 249,999249,999 to 499,999500,000 to 999,9991,000,000 or morePlease 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 ExplainDo 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 - EPLIAggregate Limit Amount$10,000$25,000$50,000$100,000$250,000$500,000$1,000,000$2,000,000Deductible$1,000$2,500$5,000$10,000$25,000# 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 - VoluntaryGive % Of Voluntary Employee Turnover (Employee Chooses To Leave) for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 MonthsEmployee Turnover Summary - InvoluntaryGive % Of Involuntary Employee Turnover (Employee Is Terminated (non layoff)) for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 MonthsEmployee Turnover Summary - LayoffGive % Of Layoff Employee Turnover for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 MonthsEmployee Turnover Summary - OtherGive % Of Other (if doesn't fit above circumstances) Employee Turnover for the following: 1. Last Year 2. Current Year 3. Projected Upcoming 12 MonthsAre 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 - PollutionDescription of pollutant type(s)Quantity Stored Of Each Pollutant TypeSpecify the type and quantity if more than 1 Pollutant TypeQuantity Stored At Job Of Each Pollutant TypeSpecify the type and quantity if more than 1 Pollutant TypeDescription of where and how pollutants are stored (on and off premises)Specify the type and quantity if more than 1 Pollutant TypeBUSINESS AUTO INSURANCE SECTIONIs 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 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?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 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 faultCOMMERCIAL UMBRELLA INSURANCE SECTIONIs 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 DescribeDo underlying insurance policies cover these exposures? Yes No Are there any operations not covered by the schedule of underlying policies? No Yes ExplainHas the applicant had any general liability or auto liability claims greater than $250,000 in the past 5 years No Yes Give Claim Detail1. 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 SECTIONIf you have any "Contracting" Exposure Check "YES" Yes No If in doubt, check "YES"Workers Compensation - Include/Exclude SectionNumber of Owners | Officers | Partners12345Owner | 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 | CompensationOwner | Officer | Partner 1 - Include | Exclude From CoverageExcludeIncludeOwner | 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 | CompensationOwner | Officer | Partner 2 - Include | Exclude From CoverageExcludeIncludeOwner | 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 | CompensationOwner | Officer | Partner 3 - Include | Exclude From CoverageExcludeIncludeOwner | 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 | CompensationOwner | Officer | Partner 4 - Include | Exclude From CoverageExcludeIncludeOwner | 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 | CompensationOwner | Officer | Partner 5 - Include | Exclude From CoverageExcludeIncludeWorkers Compensation - General UnderwritingTotal 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 ExplainHas 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 ExplainHas the Applicant filed for bankruptcy in the past 5 years? No Yes ExplainDo employees or Applicant own or operate any aircraft or watercraft? No Yes ExplainAre employees exposed under U.S. Longshoremen's and Harborworkers' Act of the Federal Employee's Liability Act? No Yes ExplainIs there any donated labor No Yes Workers Compensation - Contractors SupplementalDoes 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 jobsDoes the organization perform ANY work 6 feet or higher? No Yes Please Upload Any Relevant Documents You May Have Drop files here or Select files Max. file size: 60 MB. Δ
