Erie Insurance Ultrapack Insurance Application Questions

ALLCHOICE Agent Information

Select Your Advisor*

INSURED INFORMATION

Applicant Name (Name of Business)*

Primary Contact*

First Last

Mobile Phone*

Primary Email*

Are Mailing & Location Address Different

No
Yes

Mailing Address

Street Address City State ZIP Code

Location Address

Street Address City State ZIP Code

Are there additional locations?

No
Yes

List other locations (include full address)

Legal Entity Type

Tax | Federal ID

Number of years in business

Number of Employees

Annual Revenue

Annual Payroll

Pay Plan Selection*

EXPOSURE IDENTIFICATION

Check 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 INFORMATION

Number of Buildings/Locations

Building 1 - Construction

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 - Construction

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 - Construction

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 UNDERWRITING

Is 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

Explain

Has the Applicant ever failed to maintain liability or property insurance on this business during the past 5 years?*

No
Yes

Previous Carrier

Explain

Are 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

Explain

Has 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

Explain

Any operations sold, acquired or discontinued in the last 5 years?*

No
Yes

Explain

Is the Applicant involved in manufacturing, mixing, relabeling, or repackaging or products?*

No
Yes

Explain

Does the Applicant sell or distribute foreign products not purchased from a US distributor?*

No
Yes

Explain

Does 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 INFORMATION

Has 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 SUPPLEMENTAL

Do 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 lease

Do ALL buildings have a lease agreement requiring tenants to carry their own insurance with certificates provided to the building owner?

Yes
No

Explain

Do 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

Explain

Do ANY buildings contain student housing, assisted living, or seasonal/timeshare occupancies?

No
Yes

Explain

Do ANY buildings have recreational facilities, such as swimming pools, exercise equipment, playground, tennis court, dock/boat slips, etc?

No
Yes

Describe recreational facilities present

Do ANY buildings have a lake, pond or reservoir on premises?

No
Yes

Please describe, including size and depth

SUPPLEMENTAL UNDERWRITING QUESTIONS - DATA BREACH

Data Breach Response Expenses - Increased Coverage Limit

Data Breach Liability

How many customers/employees/patients/clients/tenants' information do you have on file?

Please 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

Explain

Do 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 - EPLI

Aggregate Limit Amount

Deductible

# Of Full Time Employees

# Of Full Part Employees

Retro-Active Date (If Current EPLI Coverage In Force)

MM

DD

YYYY

ALLCHOICE Agent Information

INSURED INFORMATION

EXPOSURE IDENTIFICATION

LOCATION | BUILDING INFORMATION

GENERAL UNDERWRITING

CLAIMS INFORMATION

HABITATIONAL SUPPLEMENTAL

SUPPLEMENTAL UNDERWRITING QUESTIONS - DATA BREACH

SUPPLEMENTAL UNDERWRITING QUESTIONS - EPLI

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