ERIE INSURANCE HOMEOWNERS UNDERWRITING QUESTIONS


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

Person(s) completing questions:  

Email:        

A. Have you ever had similar insurance on this or any other property during the past 5 years with any company
   other than the ERIE?          
   If yes, with what companies?  


B. Has any company declined, cancelled or refused to renew any similar insurance (Non-Pay cancellation 
   or previous carrier request that coverage be purchased from another company is the same as being 
   cancelled or declined)?  
   If yes, with what companies and reason?  


C. Has the Applicant had any loss, such as fire, windstorm, theft, liability, etc... on this or any other 
   property during the last 5 years?        
   If yes, with what companies and give details?  



D. Are there any Wood Burning Stoves, Fireplace Inserts, Wood Burning Furnaces, Space Heaters, or 
   Kerosene Heaters on the premises?  
   If yes, list Type, Model, UL Approved, and how often cleaned?  



E. Is there a swimming pool on the premises?  
    If inground pool, is it completely enclosed with at least a 3 foot fence and a locked gate?  


F. Are there animals, including farm animals or pets on the premises?   
   If yes, with what type of animal and breed?  



G. Is Applicant conducting any business, farming or occupational pursuits at the premises?  
   If yes, describe?  

H. Year of Construction:  
   If home in course of construction, give expected completion date:  

I. Has the roof been updated?  
   If yes, when?  

J. Has the central heating been updated?  
   If yes, when?  
 	

K. Type of Electrical Service:          
   Has it been update or inspected?     
   If yes, when?  


L. Has the dwelling been listed for sale or rent by the Applicant within the last 5 years?  
   If yes, when?  


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

 Name               Relationship              DOB
          
          
          
          


Employer
Insured 1:    
Company:      
Address 1:    
Address 2:    
City, ST Zip: 

Occupation:   
SSN:          


Employer
Insured 2:    
Company:      
Address 1:    
Address 2:    
City, ST Zip: 

Occupation:   
SSN:          




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

First Mortgagee
Lender:       
              
Address 1:    
Address 2:    
City, ST Zip: 

Loan Number:  


Second Mortgagee
Lender:       
              
Address 1:    
Address 2:    
City, ST Zip: 

Loan Number:

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

 
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