Erie Insurance Workers Compensation Insurance Application Questions ALLCHOICE Agent InformationSelect Your Advisor*Jack WingateMichael ReeseJared BellmundAJ BrowerWilliam HeasleyINSURED INFORMATIONApplicant Name (Name of Business)*Primary Contact* First Last Mobile Phone*Primary Email* Are Mailing & Location Address DifferentNoYesMailing 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?NoYesList other locations (include full address)Legal Entity TypeCorporationLimited Liability Corporation (LLC)IndividualJoint VentureLimited Liability Partnership (LLP)Non ProfitPartnershipOtherTax | Federal IDNumber of years in businessNumber of EmployeesAnnual RevenueAnnual PayrollPay Plan Selection*AnnualMonthly Draft/EFTOther (Prior Approval Needed)CONTRACTING EXPOSUREIf you have any "Contracting" Exposure Check "YES"YesNoIf in doubt, check "YES"INDIVIDUALS INCLUDED / EXCLUDEDNumber of Owners | Officers | Partners12345Owner | Officer | Partner 1 First Last Owner | Officer | Partner 1 - Date of Birth Date Format: MM slash DD slash YYYY Owner | Officer | Partner 1 - TitleOwner | Officer | Partner 1 - Ownership %Owner | Officer | Partner 1 - DutiesOwner | Officer | Partner 1 - Payroll | CompensationOwner | Officer | Partner 1 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 2 First Last Owner | Officer | Partner 2 - Date of Birth Date Format: MM slash DD slash YYYY Owner | Officer | Partner 2 - TitleOwner | Officer | Partner 2 - Ownership %Owner | Officer | Partner 2 - DutiesOwner | Officer | Partner 2 - Payroll | CompensationOwner | Officer | Partner 2 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 3 First Last Owner | Officer | Partner 3 - Date of Birth Date Format: MM slash DD slash YYYY Owner | Officer | Partner 3 - TitleOwner | Officer | Partner 3 - Ownership %Owner | Officer | Partner 3 - DutiesOwner | Officer | Partner 3 - Payroll | CompensationOwner | Officer | Partner 3 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 4 First Last Owner | Officer | Partner 4 - Date of Birth Date Format: MM slash DD slash YYYY Owner | Officer | Partner 4 - TitleOwner | Officer | Partner 4 - Ownership %Owner | Officer | Partner 4 - DutiesOwner | Officer | Partner 4 - Payroll | CompensationOwner | Officer | Partner 4 - Include | Exclude From CoverageExcludeIncludeOwner | Officer | Partner 5 First Last Owner | Officer | Partner 5 - Date of Birth Date Format: MM slash DD slash YYYY Owner | Officer | Partner 5 - TitleOwner | Officer | Partner 5 - Ownership %Owner | Officer | Partner 5 - DutiesOwner | 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?YesNoIs this policy a rewrite of a current ERIE policy?NoYesGive Policy NumberDo any employees have any "out of state" exposure, outside of primary state?NoYesExplainHas 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)?NoYesExplainHas the Applicant filed for bankruptcy in the past 5 years?NoYesExplainDo employees or Applicant own or operate any aircraft or watercraft?NoYesExplainAre employees exposed under U.S. Longshoremen's and Harborworkers' Act of the Federal Employee's Liability Act?NoYesExplainIs there any donated laborNoYesCONTRACTOR'S SUPPLEMENTAL QUESTIONSDoes the organization have a formal accident investigation procedure in place?YesNoHas the organization had any OSHA citations in the last 5 years?YesNoDoes the organization offer an Early Return-to-Work/Light/Duty Program?YesNoIn 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?NoYes
