Erie Insurance Workers Compensation 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)CONTRACTING EXPOSUREIf you have any "Contracting" Exposure Check "YES" Yes No If in doubt, check "YES"INDIVIDUALS INCLUDED / EXCLUDEDNumber of Owners | Officers | Partners12345Owner | Officer | Partner 1 First Last Owner | Officer | Partner 1 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 1 - Title Owner | Officer | Partner 1 - Ownership % Owner | Officer | Partner 1 - Duties Owner | Officer | Partner 1 - Payroll | CompensationOwner | Officer | Partner 1 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 2 First Last Owner | Officer | Partner 2 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 2 - Title Owner | Officer | Partner 2 - Ownership % Owner | Officer | Partner 2 - Duties Owner | Officer | Partner 2 - Payroll | CompensationOwner | Officer | Partner 2 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 3 First Last Owner | Officer | Partner 3 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 3 - Title Owner | Officer | Partner 3 - Ownership % Owner | Officer | Partner 3 - Duties Owner | Officer | Partner 3 - Payroll | CompensationOwner | Officer | Partner 3 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 4 First Last Owner | Officer | Partner 4 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 4 - Title Owner | Officer | Partner 4 - Ownership % Owner | Officer | Partner 4 - Duties Owner | Officer | Partner 4 - Payroll | CompensationOwner | Officer | Partner 4 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 5 First Last Owner | Officer | Partner 5 - Date of Birth MM slash DD slash YYYY Owner | Officer | Partner 5 - Title Owner | Officer | Partner 5 - Ownership % Owner | Officer | Partner 5 - Duties Owner | Officer | Partner 5 - Payroll | CompensationOwner | Officer | Partner 5 - Include | Exclude From CoverageExcludeIncludeGENERAL UNDERWRITINGTotal Number Of Workers' Comp Claims in the past 5 years?Does Applicant have any vehicles titled to the business? Yes No Is this policy a rewrite of a current ERIE policy? No Yes Give Policy Number Do any employees have any "out of state" exposure, outside of primary state? 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 ExplainHas the Applicant filed for bankruptcy in the past 5 years? No Yes ExplainDo employees or Applicant own or operate any aircraft or watercraft? No Yes ExplainAre employees exposed under U.S. Longshoremen's and Harborworkers' Act of the Federal Employee's Liability Act? No Yes ExplainIs there any donated labor No Yes CONTRACTOR'S SUPPLEMENTAL QUESTIONSDoes the organization have a formal accident investigation procedure in place? Yes No Has the organization had any OSHA citations in the last 5 years? Yes No Does the organization offer an Early Return-to-Work/Light/Duty Program? Yes No In the past two (2) years, what percentage of the organization's work has been Residential? In the past two (2) years, what percentage of the organization's work has been Commercial? Does the organization perform any of the operations below? (Check all that apply) Tree Trimming Iron Steel Erection EIFS (Exterior Insulation & Finish Systems) Roofing Blasting Demolition Hazardous Material Handling Asbestos Removal Lead Abatement Mold Remediation Fire Restoration Hire Subcontractors Describe the type of work you performed within the past 5 years and/or five jobsDoes the organization perform ANY work 6 feet or higher? No Yes Δ
