Erie Insurance General 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 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?NoYesHas Applicant filed for bankruptcy in the last seven years?NoYesIs the Applicant a Subsidiary of another entity?NoYesDoes the Applicant have any subsidiaries?NoYesAny exposure to flammables, explosives or chemicals?NoYesOperations involve discharge of fumes, acids or wastes?NoYesEquipment loaned/rented to others?NoYesDoes Applicant lease equipment with/without operators?NoYesHas the Applicant ever installed EIFS (Exterior Insulation & Finish Systems) a/k/a synthetic stucco or dryvit on buildings?NoYesIs any demolition exposure contemplated?NoYesAre there any subcontractors?NoYesNumberDoes Applicant require certificates of insurance from subcontractors?NoYesDoes Applicant have knowledge of any outstanding potential claims?NoYesDoes the Applicant engage in any operations involving aerospace or aircraft parts or perform any work at or in any airports?NoYesIs business seasonal or part-time?NoYesDoes Applicant act as a general contractor?NoYesDoes Applicant perform separate roofing operations?NoYesHow many times per yearAre there premises containing elevators?NoYesGive locations & number of elevators at each location & typeNumber of active partners | member | or corporate officersAny work performed underground or above 15 feet?NoYesADDITIONAL 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?NoYesExplain and give reasonHas any similar insurance been cancelled for non-payment of premium?NoYesExplain and give reasonHas applicant has similar insurance in the past 5 years?NoYesWhat companies?Has applicant had any losses in the last 5 years that would have been covered by this type of policy?NoYesExplainWhat was prior usage, occupancy and/or operations of this location? (if NA write "NA") This iframe contains the logic required to handle Ajax powered Gravity Forms. ShareFacebookTwitterLinkedInMorePinterestRedditEmailPrint
