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Questions for Erie Insurance Homeowners Application


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

Person(s) completing questions:

Phone Number:
Email:


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


  2. 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)?
    3. If yes, with what companies and reason?


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



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


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


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


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


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


  9. Has the roof been updated?
    10. If yes, when?


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


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


  12. Has the dwelling been listed for sale or rent by the Applicant within the last 5 years?

    13. If yes, when?


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:


List additional residents of household other than the Named Insureds.
Name Relationship DOB


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

First Mortgagee:
Address Line 1:
Address Line 2:
City, ST Zip:
Loan Number:


Second Mortgagee:
Address Line 1:
Address Line 2:
City, ST Zip:
Loan Number:


Third Mortgagee:
Address Line 1:
Address Line 2:
City, ST Zip:
Loan Number: