ERIE INSURANCE UMBRELLA UNDERWRITING QUESTIONS
ALL FIELDS ARE REQUIRED
(Please read and answer accurately - misrepresentation of fact may jeopardize coverage)
Person(s) completing questions:
Email:
A. Does Applicant own any dwellings and/or farms other than the primary residence which are rented
to others, maintained as seasonal residences, or vacant, and you did not previously list?
If Yes, please list number of families, address/location, and Occupancy (Rental, Seasonal, Vacant).
Also include the reason not previously listed.
B. Are there any motorized vehicles (Private Passenger, Commercial Automobiles, or Recreational
Motor Vehicles) which are owned, leased, or regularly furnished to the applicant or spouse that are
not covered by underlying policies?
If Yes, please list year, make/model and ownership (Owned, Leased, Furnished).
C. Has Applicant or any member of the household ever had insurance in an automobile assigned risk plan?
If Yes, please list name(s), company name and policy period.
D. Is Applicant or any member of the household an excluded driver on an underlying auto policy?
If Yes, please list excluded driver name(s).
E1. Has any driver or member of the household received a ticket for speeding or any other vehicle code
violations within the last 5 years?
If Yes, please list name(s), dates and violations:
E2. 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?
If Yes, please list name(s), dates, damage amount regardless of who was at fault.
F. Has Applicant or any member of the household had any license suspension(s) within the past 5 years?
If Yes, please list name(s), dates and reason for suspension.
G. Does Applicant or any member of the household contemplate entering automobile, recreational
motor vehicle or watercraft races, contests or exhibitions?
If Yes, please describe race, contest, or exhibition.
H. Has Applicant had any primary or excess liability insurance cancelled or denied within the past 5 years?
If Yes, please list company name, policy number, date, and reason.
I. Does the Applicant or any member of the household serve as an officer or member of the Board of
Directors of a non-profit corporation or organization?
Is there D & O Liability in force for this exposure?
If Yes, please list corporation or organization.
J. Does the Applicant employ any domestic workers?
If Yes, please list worker name(s).
K. Is there any incidental business exposure?
If Yes, please list any incidental business exposure.
L. Does the Applicant have any suits currently pending?
If Yes, please list any suits currently pending.
M. Is there any aircraft exposure?
This policy excludes personal injury and property damage liability arising out of the ownership or use
of aircraft.
Please list any aircraft exposure.
N. Is there any watercraft exposure which you did not previously list?
If Yes, please list year, type, length, horsepower, max mph, and make/model.
O. Is any member of the household a Youthful Driver (unmarried under age 24)?
If Yes, please list each driver's Name DOB and License Number.
List all other residents of household other than the named insured(s) or household drivers.
Name Relationship DOB
Employer
Insured 1:
Company:
Address 1:
Address 2:
City, ST Zip:
Occupation:
Employer
Insured 2:
Company:
Address 1:
Address 2:
City, ST Zip:
Occupation:
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