Questions for Erie Insurance Auto Application

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

Person(s) completing questions:

Phone Number:
Email:

	Name	Drivers License ST & No.	Approx. Date Licensed	Date of Birth
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5

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 additional residents of household that are not listed above as drivers.

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:
Vehicle 5 Approx. Purchase Date:

Current Insurance Company:
Current Policy Number:

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

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

Lienholders: must be listed exactly as they appear previous declarations page or loan paperwork.

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

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

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

Vehicle 4 Lender:
Address Line 1:
Address Line 2:
City, ST Zip:

Vehicle 5 Lender:
Address Line 1:
Address Line 2:
City, ST Zip: