Erie Insurance Ultrapack 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* Are Mailing & Location Address Different No Yes 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 Location 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 Are there additional locations? No Yes List other locations (include full address)Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal ID Number of years in business Number of Employees Annual RevenueAnnual PayrollPay Plan Selection*AnnualMonthly Draft/EFTOther (Prior Approval Needed)EXPOSURE IDENTIFICATIONCheck any/all of the exposures that apply (or that your ALLCHOICE Adivsor asked you to check)Select The Primary Coverage(s)* Building Business Personal Property Equipment | Machinery Select The Additional Coverage(s)* None Employment Practices Liability (EPLI) Data Breach Do you have a Retail or Wholesale Exposure?* Yes No Check any/all of the Supplemental Exposures Below Habitational Contractor Manufacturing LOCATION | BUILDING INFORMATIONNumber of Buildings/Locations123Building 1 - ConstructionFrameBrick/Masonry VeneerJoisted Masonry (walls are block with frame roof)Masonry Non Combustible (black with non-wood roof)Building 1 - Total Sqft Building 1 - # of Stories Building 1 - Year Built Building 1 - Year Of Updates for Plumbing | Electric | HVAC | Roof (if none say none)Building 1 - Protective Devices (check all that apply) Sprinklered - 100% Sprinklered - Less Than 100% Fire Alarm - Central Station Fire Alarm - Local (not monitored) Burglar Alarm - Central Station Burglar Alarm - Local (not monitored) Building 2 - ConstructionFrameBrick/Masonry VeneerJoisted Masonry (walls are block with frame roof)Masonry Non Combustible (black with non-wood roof)Building 2 - Total Sqft Building 2 - # of Stories Building 2 -Year Built Building 2 - Year Of Updates for Plumbing | Electric | HVAC | Roof (if none say none)Building 2 - Protective Devices (check all that apply) Sprinklered - 100% Sprinklered - Less Than 100% Fire Alarm - Central Station Fire Alarm - Local (not monitored) Burglar Alarm - Central Station Burglar Alarm - Local (not monitored) Building 3 - ConstructionFrameBrick/Masonry VeneerJoisted Masonry (walls are block with frame roof)Masonry Non Combustible (black with non-wood roof)Building 3 - Total Sqft Building 3 - # of Stories Building 3 - Year Built Building 3 - Year Of Updates for Plumbing | Electric | HVAC | Roof (if none say none)Building 3 - Protective Devices (check all that apply) Sprinklered - 100% Sprinklered - Less Than 100% Fire Alarm - Central Station Fire Alarm - Local (not monitored) Burglar Alarm - Central Station Burglar Alarm - Local (not monitored) GENERAL UNDERWRITINGIs this policy a rewrite of a current ERIE policy?* No Yes Give Policy Number Are there any other premises or operations which are not to be covered by this insurance?* No Yes ExplainHas the Applicant ever failed to maintain liability or property insurance on this business during the past 5 years?* No Yes Previous Carrier ExplainAre there premises containing elevators?* No Yes Has the Applicant ever been cancelled (including nonpay) or refused insurance of any kind by The ERIE or any other insurance carrier?* No Yes ExplainHas the Applicant or any partner, corporate officer, member or director ever been convicted or otherwise found guilty of a crime (excluding offenses committed while a juvenile or sealed by court order)?* No Yes Explain (give date, place and reason for arrest. if convicted, give penalty)Has the Applicant filed for bankruptcy in the past 5 years?* No Yes ExplainAny operations sold, acquired or discontinued in the last 5 years?* No Yes ExplainIs the Applicant involved in manufacturing, mixing, relabeling, or repackaging or products?* No Yes ExplainDoes the Applicant sell or distribute foreign products not purchased from a US distributor?* No Yes ExplainDoes the Applicant install, service or assemble any product?* No Yes Does the Applicant rent or loan equipment to others?* No Yes Does the Applicant offer any skin tanning services or operate any skin tanning equipment?* No Yes Retail % of Sales (if none write "$0") Wholesale % of Sales (if none write "$0") Internet Sales % of Sales (if none write "$0") Installation/Service % of Sales (if none write "$0") CLAIMS INFORMATIONHas Applicant had any claims in the past 5 years (General Liability, Property, Etc)* No Yes Claim Info (Give Date, Approx Amount, Brief Explanation for all claims)HABITATIONAL SUPPLEMENTALDo ALL buildings have two separate exits from each unit? Yes No Describe the means of egress from the building(s)Do ALL buildings have hardwired smoke detectors with battery backup OR smoke detectors with long life lithium batteries installed in every unit? Yes No Do ALL buildings have a fire alarm system? Yes No Do ALL buildings have carbon monoxide detectors installed in all units that have gas appliances or fireplaces? Yes No Do ALL buildings have multi-purpose fire extinguishers available in all hallways and common areas? Yes No Do ALL buildings have emergency lighting installed in all common areas? Yes No No Common Areas Do ALL buildings require written, 12 month leases (or greater)? Yes No Please describe leaseDo ALL buildings have a lease agreement requiring tenants to carry their own insurance with certificates provided to the building owner? Yes No ExplainDo ALL buildings have an occupancy rate of 80% or higher? Yes No Provide Actual Occupancy Rate Do ANY buildings all grilling or other outdoor fires within 10 feet of any structure? No Yes ExplainDo ANY buildings contain student housing, assisted living, or seasonal/timeshare occupancies? No Yes ExplainDo ANY buildings have recreational facilities, such as swimming pools, exercise equipment, playground, tennis court, dock/boat slips, etc? No Yes Describe recreational facilities presentDo ANY buildings have a lake, pond or reservoir on premises? No Yes Please describe, including size and depthSUPPLEMENTAL UNDERWRITING QUESTIONS - DATA BREACHData Breach Response Expenses - Increased Coverage Limit$10,000$25,000$50,000$100,000$250,000$500,000$1,000,000Data Breach Liability$10,000$25,000$50,000$100,000$250,000$500,000$1,000,000How many customers/employees/patients/clients/tenants' information do you have on file?1 to 9,99910,000 to 24,99925,000 to 49,99950,000 to 149,999150,000 to 249,999249,999 to 499,999500,000 to 999,9991,000,000 or morePlease check (all that apply) which of the following types of data you collect, store, manage or process containing the following Personally Identifiable Information, Payment Card Information, or Health Information Social Security Numbers Banking / Financial Information Credit Cards / Debit Cards / Other Payment Cards Health Information & Medical Records None Please check (all that apply) the computer security controls that are currently in place Anti-Virus Software Password Protected computers, laptops, and other mobile devices Secured wireless connectivity for laptops and other mobile devices Firewall Data stored on laptops, back-up tapes, or other portable media is encrypted None Have you suffered a breach of personal information, including loss or theft of laptops, smart phones, etc? No Yes ExplainDo you conduct annual training for employees concerning data security and the handling of personal information? Yes No Do you post and circulate your document retention and destruction policy to your employees? Yes No SUPPLEMENTAL UNDERWRITING QUESTIONS - EPLIAggregate Limit Amount$10,000$25,000$50,000$100,000$250,000$500,000$1,000,000$2,000,000Deductible$1,000$2,500$5,000$10,000$25,000# Of Full Time Employees # Of Full Part Employees Retro-Active Date (If Current EPLI Coverage In Force) Month Day Year Δ
