Erie Insurance Five Star Liability 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* 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 UNDERWRITINGDoes the policy have more than one named insured? No Yes Any exposure to flammables, explosives or chemicals? No Yes Does Applicant lease equipment with/without operators? No Yes Will the applicant accept jobs that are solely new roofing or re-roofing? No Yes Has the Applicant ever installed EIFS (Exterior Insulation & Finish Systems) a/k/a synthetic stucco or dryvit on buildings? No Yes Does applicant subcontract any work? No Yes Cost of subcontract work?Are Certificates of Insurance Required? Yes No Does the Applicant engage in any operations involving aerospace or aircraft parts or perform any work at or in any airports? No Yes Has Applicant been in business less than 1 year? No Yes Give Experience (including number of years) in similar type business of industryAre the liability limits requested in excess of $1,000,000 / $2,000,000 No Yes Is the total Value of Building & Contents in excess of $1,000,000? No Yes Is any ONE Inland Marine Coverage in excess of $100,000? No Yes Has Applicant had any claims in the past 5 years? No Yes Has the Applicant ever failed to maintain liability of property insurance on this business during the past 5 years? No Yes Are there premises containing elevators? No Yes Give locations & number of elevators at each location & typeHas the Applicant ever been cancelled or refused insurance of any kind by The ERIE or any other insurance carrier? No Yes Has the Applicant(s) ever been arrested for any reason? No Yes Has Applicant filed for bankruptcy in the last five years? No Yes Upload Any Files Drop files here or Select files Max. file size: 60 MB. Δ
