Erie Insurance Five Star Liability Insurance Application QuestionsALLCHOICE Agent InformationSelect Your Advisor*Jack WingateMichael ReeseJared BellmundAJ BrowerWilliam HeasleyINSURED INFORMATIONApplicant Name (Name of Business)Primary Contact First Last Mobile PhonePrimary Email Mailing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal IDNumber of EmployeesAnnual RevenueAnnual PayrollYear Business StartedBusiness Description (What Do You Do)Pay Plan SelectionAnnualMonthly Draft/EFTOther (Prior Approval Needed)GENERAL UNDERWRITINGDoes the policy have more than one named insured?NoYesAny exposure to flammables, explosives or chemicals?NoYesDoes Applicant lease equipment with/without operators?NoYesWill the applicant accept jobs that are solely new roofing or re-roofing?NoYesHas the Applicant ever installed EIFS (Exterior Insulation & Finish Systems) a/k/a synthetic stucco or dryvit on buildings?NoYesDoes applicant subcontract any work?NoYesCost of subcontract work?Are Certificates of Insurance Required?YesNoDoes the Applicant engage in any operations involving aerospace or aircraft parts or perform any work at or in any airports?NoYesHas Applicant been in business less than 1 year?NoYesGive Experience (including number of years) in similar type business of industryAre the liability limits requested in excess of $1,000,000 / $2,000,000NoYesIs the total Value of Building & Contents in excess of $1,000,000?NoYesIs any ONE Inland Marine Coverage in excess of $100,000?NoYesHas Applicant had any claims in the past 5 years?NoYesHas the Applicant ever failed to maintain liability of property insurance on this business during the past 5 years?NoYesAre there premises containing elevators?NoYesGive 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?NoYesHas the Applicant(s) ever been arrested for any reason?NoYesHas Applicant filed for bankruptcy in the last five years?NoYesUpload Any Files Drop files here or This iframe contains the logic required to handle Ajax powered Gravity Forms. ShareFacebookTwitterLinkedInMorePinterestRedditEmailPrint
