ERIE INSURANCE AUTO UNDERWRITING QUESTIONS

ALL FIELDS ARE REQUIRED
(Please read and answer accurately - misrepresentation of fact may jepordize coverage)

Person(s) completing questions:  

Email:  

A: Has any driver or member of the household had any auto insurance refused, cancelled or expired in 
   the past 5 years, or been excluded or restricted on a policy in the past 5 years? 
      
      NO
      YES
    

   If yes, give name of Company, Policy No., date and reason if known.  
   


B: Has any driver or member of the household been required to file evidence of financial responsibility
   in the past 5 years?  
      
      NO
      YES
    

   If yes, give date and reason:  
   


C: Has any driver or member of the household had their driver's license or driving privileges revoked or
   suspended in the past 5 years?  
      
      NO
      YES
    

   If yes, list driver and give date and reason:  
   


D: Has any driver or member of the household received a ticket for speeding, a PJC, or any other 
   vehicle code violation in the past 5 years?  
      
      NO
      YES
    

   If yes, give Driver, details and violation, for speeding give Speed Limit and M.P.H. over the limit):
   
   
   


E: Has any driver or member of the household ever been arrested for ANY reason?  
      
      NO
      YES
    

  Give date, place of arrest, conviction and penalty:
  


F: Has any driver or member of the household of driving age had a physical or mental impairment 
   or disability or other medical infirmity?  
      
      NO
      YES
    

   Identify any such condition (e.g., heart, diabetes, epilepsy, hearing/sight/limb loss, back condition 
   or other medical infirmity), its duration and treatment obtained and/or medication prescribed:
   


G. Has any driver or member of the household had any Comprehensive losses (deer, fire, glass breakage, 
   theft, etc.) in the past 5 years?  
      
      NO
      YES
    

   List driver and describe all incidents:  
                                            
                                            


H: Has any driver or member of the household, while driving a motor vehicle, been involved in 
   an accident or reported a claim to an insurance company during the past 5 years?  
      
      NO
      YES
    

   List driver(s) and describe all incidents, regardless of who was at fault.
   
   
   


List all other residents of household other than the named insured(s).

 Name                   Relationship          DOB
  ChildSiblingParentother relativenon-relative  
  ChildSiblingParentother relativenon-relative  
  ChildSiblingParentother relativenon-relative  
  ChildSiblingParentother relativenon-relative  


Additional Info Required

Vehicle 1 Approx. Purchase Date: 
Vehicle 2 Approx. Purchase Date: 
Vehicle 3 Approx. Purchase Date: 
Vehicle 4 Approx. Purchase Date: 


Current Insurance Company: 
Current Policy Number:     


Insured 1:           
License State and #: 
Employer:            
Address 1:           
Address 2:           
City, ST Zip:        

Insured 2:           
License State and #: 
Employer:            
Address 1:           
Address 2:           
City, ST Zip:        



Other Interests must be exactly at listed on previous declarations page or loan paperwork: 

Lienholders
Vehicle 1 Lender: 
                  
Address 1:        
Address 2:        
City, ST Zip:     


Vehicle 2 Lender: 
                  
Address 1:        
Address 2:        
City, ST Zip:     


Vehicle 3 Lender: 
                  
Address 1:        
Address 2:        
City, ST Zip:     

Phone: 919.267.3063
Fax: 866.453.9992
E-mail: agency@abc-insure.com

Address:
ABC INSURANCE AGENCY
800 W. Williams St, Suite 231-C
Apex, NC 27502