Erie Insurance Commercial Umbrella Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*Heather BaileyAJ BrowerCheyenne MathewsMichael ReeseEd JohnsonBill HeasleyJeff HallJared BellmundJack WingateINSURED INFORMATIONApplicant Name (Name of Business)* Primary Contact* First Last Mobile Phone*Primary Email* 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 Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal ID Number of Employees Annual RevenueAnnual PayrollYear Business Started Business Description (What Do You Do)Pay Plan SelectionAnnualMonthly Draft/EFTOther (Prior Approval Needed)GENERAL UNDERWRITINGIs 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)Upload Any Files Drop files here or Select files Max. file size: 60 MB. Δ
