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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)
Month
Day
Year

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