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)

MM

DD

YYYY

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

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

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

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

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

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)

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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