First Name*
Last Name*
Email*
Phone*
Date Of Birth (MM/DD/YYYY)*
Do You Currently Have Active Policies With Us?* Do You Currently Have Active Policies With Us? Yes No
For new clients home quote requests, we require auto insurance to be included in the bundle. Preferred Contact Method Preferred Contact Method Phone Email Text
Type of Insurance* Type of Insurance Homeowners Insurance Auto Insurance Homeowners & Auto Insurance Bundle Business Insurance Life Insurance
Type of Insurance* Type of Insurance Auto Insurance Homeowners & Auto Insurance Bundle Business Insurance Life Insurance
North Carolina Consent* I certify that I reside in North Carolina, am relocating to the state, or own property or a registered business within North Carolina.
Terms and Conditions* Property Address to Quote Street Address*
Second Address Line (Suite, Apartment, or Building #)
City*
State*
Zip Code*
Is This Address Also The Mailing Address?* Is This Address Also The Mailing Address? Yes No
Mailing Address (Street Address/City/State/Zip Code)*
Desired coverage effective date (MM/DD/YYYY)*
Homeowners Insurance Do you currently have homeowners insurance?* Do you currently have homeowners insurance? Yes No
Current Insurance Company
Policy expiration date (MM/DD/YYYY)
Do you have a current homeowners insurance declaration page?* Do you have a current homeowners insurance declaration page? No Yes
Please upload it here:
Others Listed on Deed:* Others Listed on Deed: Yes No
Number Of Extra Persons Listed On Deed* Others Listed on Deed: 1 2 3
First Additional Person Listed On Deed First Name*
Last Name*
Date Of Birth (MM/DD/YYYY)*
Second Additional Person Listed On Deed First Name*
Last Name*
Date Of Birth (MM/DD/YYYY)*
Third Additional Person Listed On Deed First Name*
Last Name*
Date Of Birth (MM/DD/YYYY)*
Homeowners Insurance Information For How Long You Have Been At This Property?* For How Long You Have Been At This Property? 0-3 years 4+ years
Prior Property Street Address*
Prior Property Second Address Line (Suite, Apartment, or Building #)
Prior Property City*
Prior Property State*
Prior Property Zip Code*
Is this your primary residence?* Is this your primary residence? Yes No
Year property was built*
Purchase Price $
Type Of Property* Type Of Property Single-family home Condo Townhouse Multi-family Mobile home
Square footage*
Number of stories*
Number of bathrooms*
Roof Type Roof Type Asphalt Shingles Metal Architectural Other
Other Roof Type
Roof Age*
Exterior wall material (brick, siding, stucco, etc.)
Heating System* Heating System Gas Electric
Heating System Year Updated
Cooling System* Cooling System Central Other
Cooling System Year Updated
Any galvanized, cast iron, PEX or polybutylene Pipes? Any galvanized, cast iron, PEX or polybutylene Pipes? Yes No
Garage type Garage type Attached Detached None
Attached Garage Type Garage type One Car Two Cars Three Cars
Basement* Basement Yes - Finished Yes - Unfinished No
Safety Features* Do you own any high-value items you’d like to insure separately (jewelry, art, collectibles)? Do you own any high-value items you’d like to insure separately (jewelry, art, collectibles)? Yes No
Any recent claims in the past 5 years?* Any recent claims in the past 5 years? Yes No
Please describe claim*
Do you run a business from your home?* Do you run a business from your home? Yes No
Do you have any pets?* Do you have any pets? Yes No
How Many Pets? How Many Pets? 1 2 3 4 5
First Pet's Type and Breed*
Second Pet's Type and Breed*
Third Pet's Type and Breed*
Fourth Pet's Type and Breed*
Fifth Pet's Type and Breed*
Address Street Address*
Second Street Line (Suite, Apartment, or Building #)
City*
State*
Zip Code*
Is This Address Also The Mailing Address?* Yes No
Mailing Address (Street Address/City/State/Zip Code)*
Auto Insurance Do You Currently Have Auto Insurance?* Do You Currently Have Auto Insurance? No Yes
Current insurance company
Policy expiration date (MM/DD/YYYY)
Desired Coverage Effective Date (MM/DD/YYYY)*
Do you have a current auto insurance declaration page?* Do you have a current auto insurance declaration page? No Yes
Please upload it here:
Coverage Limits Liability Limits* Liability Limits 100/300/100 250/500/100 Other
Other Liability Limit*
Medical Payments Coverage* Medical Payments Coverage $1,000 $2,000 $5,000 $10,000 None
Uninsured/Underinsured Motorist Limits* Uninsured/Underinsured Motorist Limits 100/300/100 250/500/100 Other
Other Uninsured/Underinsured Motorist Limits*
Number Of Vehicles* Number Of Vehicles 1 2 3 4 5
Vehicle Information Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership* Ownership Owned Financed Leased
Primary Use* Primary Use Pleasure Drive to Work less than 10 miles Drive to Work more than 10 miles Business
Primary Driver*
Towing* Towing Yes No
Extended Transportation Vehicle 1* Extended Transportation Vehicle 1 Yes No
Extended Transportation Amount Vehicle 1* Extended Transportation Amount Vehicle 1 $30/Day - $900/Loss $50/Day - $1,500/Loss
Comprehensive Coverage?* Comprehensive Coverage? Yes No
Comprehensive Deductible Preference* Comprehensive Deductible Preference None No Deductible $100 $250 $500 $1,000
Collision Coverage?* Collision Coverage? Yes No
Collision Deductible Preference* Collision Deductible Preference None No Deductible $100 $200 $250 $500 $1,000
Any customized equipment?* Any customized equipment? Yes No
Value of customized equipment*
Vehicle Information 2 Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership* Ownership Owned Financed Leased
Primary Use* Primary Use Pleasure Drive to Work less than 10 miles Drive to Work more than 10 miles Business
Primary Driver*
Towing* Towing Yes No
Extended Transportation Vehicle 2* Extended Transportation Vehicle 2 Yes No
Extended Transportation Amount Vehicle 2* Extended Transportation Amount Vehicle 2 $30/Day - $900/Loss $50/Day - $1,500/Loss
Comprehensive Coverage?* Comprehensive Coverage? Yes No
Comprehensive Deductible Preference* Comprehensive Deductible Preference None No Deductible $100 $250 $500 $1,000
Collision Coverage?* Collision Coverage? Yes No
Collision Deductible Preference* Collision Deductible Preference None No Deductible $100 $200 $250 $500 $1,000
Any customized equipment on second vehicle?* Any customized equipment? Yes No
Value of customized equipment*
Vehicle Information 3 Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership* Ownership Owned Financed Leased
Primary Use* Primary Use Pleasure Drive to Work less than 10 miles Drive to Work more than 10 miles Business
Primary Driver*
Towing* Towing Yes No
Extended Transportation Vehicle 3* Extended Transportation Vehicle 3 Yes No
Extended Transportation Amount Vehicle 3* Extended Transportation Amount Vehicle 3 $30/Day - $900/Loss $50/Day - $1,500/Loss
Comprehensive Coverage?* Comprehensive Coverage? Yes No
Comprehensive Deductible Preference* Comprehensive Deductible Preference None No Deductible $100 $250 $500 $1,000
Collision Coverage?* Collision Coverage? Yes No
Collision Deductible Preference* Collision Deductible Preference None No Deductible $100 $200 $250 $500 $1,000
Any customized equipment on third vehicle?* Any customized equipment? Yes No
Value of customized equipment*
Vehicle Information 4 Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership* Ownership Owned Financed Leased
Primary Use* Primary Use Pleasure Drive to Work less than 10 miles Drive to Work more than 10 miles Business
Primary Driver*
Towing* Towing Yes No
Extended Transportation Vehicle 4* Extended Transportation Vehicle 4 Yes No
Extended Transportation Amount Vehicle 4* Extended Transportation Amount Vehicle 4 $30/Day - $900/Loss $50/Day - $1,500/Loss
Comprehensive Coverage?* Comprehensive Coverage? Yes No
Comprehensive Deductible Preference* Comprehensive Deductible Preference None No Deductible $100 $250 $500 $1,000
Collision Coverage?* Collision Coverage? Yes No
Collision Deductible Preference* Collision Deductible Preference None No Deductible $100 $200 $250 $500 $1,000
Any customized equipment on fourth vehicle?* Any customized equipment? Yes No
Value of customized equipment*
Vehicle Information 5 Year/Make/Model*
Vehicle Identification Number (VIN)*
Ownership* Ownership Owned Financed Leased
Primary Use* Primary Use Pleasure Drive to Work less than 10 miles Drive to Work more than 10 miles Business
Primary Driver*
Towing* Towing Yes No
Extended Transportation Vehicle 5* Extended Transportation Vehicle 5 Yes No
Extended Transportation Amount Vehicle 5* Extended Transportation Amount Vehicle 5 $30/Day - $900/Loss $50/Day - $1,500/Loss
Comprehensive Coverage?* Comprehensive Coverage? Yes No
Comprehensive Deductible Preference* Comprehensive Deductible Preference None No Deductible $100 $250 $500 $1,000
Collision Coverage?* Collision Coverage? Yes No
Collision Deductible Preference* Collision Deductible Preference None No Deductible $100 $200 $250 $500 $1,000
Any customized equipment on fifth vehicle?* Any customized equipment? Yes No
Value of customized equipment*
Driver Information Driver's License Number*
State of issue*
Years licensed*
Marital Status (Single / Married / Divorced / Widowed)*
Any accidents or violations in the past 5 years?* Any accidents or violations in the past 5 years? Yes No
Any additional drivers?* Any additional drivers? Yes No
How Many Additional Drivers?* How Many Additional Drivers? 1 2 3 4 5
Additional Driver 1 Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 1* Relationship Additional Driver 1 Insured (Self) Spouse Domestic Partner Child Parent Other
Other*
Additional Driver 2 Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 2* Relationship Additional Driver 2 Insured (Self) Spouse Domestic Partner Child Parent Other
Other*
Additional Driver 3 Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 3* Relationship Additional Driver 3 Insured (Self) Spouse Domestic Partner Child Parent Other
Other*
Additional Driver 4 Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 4* Relationship Additional Driver 4 Insured (Self) Spouse Domestic Partner Child Parent Other
Other*
Additional Driver 5 Name*
Driver's License Number*
State of issue*
Relationship Additional Driver 5* Relationship Additional Driver 5 Insured (Self) Spouse Domestic Partner Child Parent Other
Other*
Life Insurance Do you qualify for Erie Express Life? Ages of 19 to 40 qualifies (NO MEDICAL EXAM REQUIRED). Do you qualify for Erie Express Life? Ages of 19 to 40 qualifies (NO MEDICAL EXAM REQUIRED). Yes No
Smoker or Non-Smoker?* Smoker or Non-Smoker? Smoker Non-Smoker
Height*
Weight*
Type of Life Insurance Policy* Type of Life Insurance Policy Term Life Whole Life
Term Policy Years* Term Policy Years 10 Years 15 Years 20 Years 30 Years
Coverage Amount $250,000, $500,000 or whatever amount preferred*
Business Insurance Do You Currently Have Business Insurance? Do You Currently Have Business Insurance? No Yes
Current Insurance Company
Policy Expiration Date (MM/DD/YYYY)
Do you have a current business insurance declaration page? Do you have a current business insurance declaration page? No Yes
Please upload it here:
Effective Date (MM/DD/YYYY)*
Name of Owner*
Owner Mailing Address (Street Address/City/State/Zip Code)*
Owner Cell Phone*
Owner Email*
Additional Owner's Name (if applicable)
Additional Owner's Email (if applicable)
Name of Business*
Business DBA
Business Street Address*
Business Second Address Line (Suite, Apartment, or Building #)
Business Address City*
Business Address State*
Business Address Zip*
Business Phone
Website (if applicable)
Federal Tax ID or SSN*
Business Entity (LLC, Corp, S-Corp, Sole Prop)*
Type of Business (Brief Description)*
Years in Business*
Years Experience in the field*
Gross Sales (est.)*
Annual Payroll (est.)*
Business Personal Property Coverage ($)
Number of Full Time Employees*
Number of Part-Time Employees*
Percentage of Work Subcontracted
Building Coverage* Building Coverage Own Rent
Building Value ($)
Building Sq. Ft. (or rental space sq ft)*
Safety Features Fire Alarm Fire Alarm Local Central None
Burglar Alarm Burglar Alarm Local Central None
Sprinkler System (0-100%)
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Email
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