Erie Insurance General 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 PayrollBusiness Description (What Do You Do)Pay Plan SelectionAnnualMonthly Draft/EFTOther (Prior Approval Needed)GENERAL UNDERWRITINGHas the Applicant(s) ever been arrested for any reason? No Yes Has Applicant filed for bankruptcy in the last seven years? No Yes Is the Applicant a Subsidiary of another entity? No Yes Does the Applicant have any subsidiaries? No Yes Any exposure to flammables, explosives or chemicals? No Yes Operations involve discharge of fumes, acids or wastes? No Yes Equipment loaned/rented to others? No Yes Does Applicant lease equipment with/without operators? No Yes Has the Applicant ever installed EIFS (Exterior Insulation & Finish Systems) a/k/a synthetic stucco or dryvit on buildings? No Yes Is any demolition exposure contemplated? No Yes Are there any subcontractors? No Yes NumberDoes Applicant require certificates of insurance from subcontractors? No Yes Does Applicant have knowledge of any outstanding potential claims? No Yes Does the Applicant engage in any operations involving aerospace or aircraft parts or perform any work at or in any airports? No Yes Is business seasonal or part-time? No Yes Does Applicant act as a general contractor? No Yes Does Applicant perform separate roofing operations? No Yes How many times per yearAre there premises containing elevators? No Yes Give locations & number of elevators at each location & typeNumber of active partners | member | or corporate officersAny work performed underground or above 15 feet? No Yes ADDITIONAL APPLICANT INFORMATIONHow long has applicant operated described business?If less than one year, give prior experienceHas any similar insurance (application or renewal) been declined or cancelled? No Yes Explain and give reasonHas any similar insurance been cancelled for non-payment of premium? No Yes Explain and give reasonHas applicant has similar insurance in the past 5 years? No Yes What companies?Has applicant had any losses in the last 5 years that would have been covered by this type of policy? No Yes ExplainWhat was prior usage, occupancy and/or operations of this location? (if NA write "NA") Δ
