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General Information
Name of Business:
Owner's Name:
Location Address:
City:   State:   Zip:
Is the mailing address the same as the location address? Y N
Mailing Address:
City:   State:   Zip:
Business Phone:   Fax:
Contact Email Address:
Business Status:   Years in Business:   # Emp:
Business Tax ID Number:
Website Address:
Been insured w/ Erie Insurance?: Yes
State(s) conducting business in?:

How Did You Hear About Us?
Please check all that apply:
Search Engine Social Network Advertisement Family or Friend
Forum/Blog Co-Worker Other:

Current Insurance Information
Please provide information on previous insurance carrier:
Previous Ins. Carrier:
Policy number:
Prior premium:
Policy renewal date:
Please provide information about your business:
Years in business:
Projected Gross annual receipts:
Projected annual payroll:
    Describe your business, product or service:
What type of coverages do you currently have:
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Group Health
Group Life
Professional Liability
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:     Premium: $
Carrier Name:     Premium: $

Property Questions
Age of building
/Year Built:
Type of building
Number of
Square feet
you occupy:
sq. ft.
If the building is over 25 years old, please answer the following:
Year Electricity was updated:

Is it on circuit breakers?:


Year Plumbing was updated:

Copper or Galvanized plumbing?:

Copper   Galvanized   Other:

Year Building was last re-roofed:

Type of roofing material:

Type of heating system in the building:

About Your Business
# of full-time
# of part-time
How long
in business
How many
Estimated Annual
Please give a brief description of your business(below):

Coverage Limits
Contents (inventory,
supplies, etc.):
Computers &
Loss of Income:
Money and
Glass or signs:
General Liability
Non-owned and Hired
Automobile Liability:
Is liquor
liability needed?
    If Glass Coverage is needed, please provide dimensions:
    Please list other coverages you may need:

Protective Devices
Burglar Alarm:
Central Station
or local alarm?:
Name of
alarm company:
Is the building
Are there
smoke detectors?:
Y   N
 Central Station
 Local Alarm
Y   N
Y   N

Miscellaneous Information
Name of Additional Insured
(Landlord or vendor):
Mailing Address:
City:   State:   Zip:

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:    Yes
Have you ever been named in litigation regarding faulty construction?:    Yes
Are there any claims or legal actions pending?:    Yes
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:    Yes

Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years.
This information is kept strictly confidential

Are there any claims or legal actions pending?    Yes

Claim #1
  Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
  Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2
  Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
  Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

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