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(919) 296-3787
Secure Quote Request
First Name
*
Last Name
*
Email
*
Phone
*
Date Of Birth
*
MM slash DD slash YYYY
Are You An Active Client?
*
Are You An Active Client?
Yes
No
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
Consent
*
I certify that I reside in North Carolina, am relocating to the state, or own property or a registered business within North Carolina. I acknowledge that by checking this box, I agree to the
Privacy Policy
and the
Terms and Conditions
of the service.
Address
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
*
Homeowners Insurance
Do you currently have homeowners insurance?
*
Do you currently have homeowners insurance?
Yes
No
Do you have a current homeowners insurance declaration page?
*
Do you have a current homeowners insurance declaration page?
No
Yes
Please upload it here:
Drop files here or
Select files
Max. file size: 59 MB.
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 slash DD slash YYYY
Second Additional Person Listed On Deed
First Name
*
Last Name
*
Date Of Birth
*
MM slash DD slash YYYY
Third Additional Person Listed On Deed
First Name
*
Last Name
*
Date Of Birth
*
MM slash DD slash YYYY
Homeowners Insurance Information
Property Address to Quote
*
For How Long You Have Been At This Property?
*
Prior Property Address
*
Is this your primary residence?
*
Is this your primary residence?
Yes
No
Do you currently live at this property?
*
Do you currently live at this property?
Yes
No
Year property was built
*
Type Of Property
*
Type Of Property
Single-family home
Condo
Townhouse
Multi-family
Mobile home
Desired coverage effective date
*
Current insurer (if applicable)
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
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
Attached Garage Type
Garage type
One Car
Two Cars
Three Cars
Safety Features
*
Security System
Fire Sprinkler System
Smoke Detector
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
Do you have any pets?
*
Do you have any pets?
Yes
No
Pet's Type and Breed
*
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
Auto Insurance
Do You Currently Have Auto Insurance?
*
Do You Currently Have Auto Insurance?
No
Yes
Do you have a current auto insurance declaration page?
*
Do you have a current auto insurance declaration page?
No
Yes
Please upload it here:
Drop files here or
Select files
Max. file size: 59 MB.
Number Of Vehicles
*
Number Of Vehicles
1
2
3
4
5
Vehicle Information
Year
*
Make
*
Model
*
Vehicle Identification Number (VIN)
*
Ownership (Owned / Financed / Leased)
*
Primary Use (Commute / Pleasure / Business)
*
Primary Driver
*
Annual Mileage
*
Any customized equipment?
*
Any customized equipment?
Yes
No
Value of customized equipment
*
Towing
*
Towing
Yes
No
Extended Transportation
*
Extended Transportation
Yes
No
Vehicle Information 2
Year
*
Make
*
Model
*
Vehicle Identification Number (VIN)
*
Ownership (Owned / Financed / Leased)
*
Primary Use (Commute / Pleasure / Business)
*
Primary Driver
*
Annual Mileage
*
Any customized equipment on second vehicle?
*
Any customized equipment?
Yes
No
Value of customized equipment
*
Towing
*
Towing
Yes
No
Extended Transportation
*
Extended Transportation
Yes
No
Vehicle Information 3
Year
*
Make
*
Model
*
Vehicle Identification Number (VIN)
*
Ownership (Owned / Financed / Leased)
*
Primary Use (Commute / Pleasure / Business)
*
Primary Driver
*
Annual Mileage
*
Any customized equipment on third vehicle?
*
Any customized equipment?
Yes
No
Value of customized equipment
*
Towing
*
Towing
Yes
No
Extended Transportation
*
Extended Transportation
Yes
No
Vehicle Information 4
Year
*
Make
*
Model
*
Vehicle Identification Number (VIN)
*
Ownership (Owned / Financed / Leased)
*
Primary Use (Commute / Pleasure / Business)
*
Primary Driver
*
Annual Mileage
*
Any customized equipment on fourth vehicle?
*
Any customized equipment?
Yes
No
Value of customized equipment
*
Towing
*
Towing
Yes
No
Extended Transportation
*
Extended Transportation
Yes
No
Vehicle Information 5
Year
*
Make
*
Model
*
Vehicle Identification Number (VIN)
*
Ownership (Owned / Financed / Leased)
*
Primary Use (Commute / Pleasure / Business)
*
Primary Driver
*
Annual Mileage
*
Any customized equipment on fifth vehicle?
*
Any customized equipment?
Yes
No
Value of customized equipment
*
Towing
*
Towing
Yes
No
Extended Transportation
*
Extended Transportation
Yes
No
Driver Information
Driver's License Number
*
State of issue
*
Years licensed
*
Marital Status (Single / Married / Divorced / Widowed)
*
Currently insured?
*
Currently insured?
Yes
No
Current insurance company (if applicable)
Policy expiration date
Any accidents or violations in the past 5 years?
*
Any accidents or violations in the past 5 years?
Yes
No
Desired Coverage Effective Date
*
Liability Limits
*
Liability Limits
100/300/100
250/500/100
Other
Other Liability Limit
*
Uninsured/Underinsured Motorist Limits
*
Uninsured/Underinsured Motorist Limits
100/300/100
250/500/100
Other
Other Uninsured/Underinsured Motorist Limits
*
Medical Payments Coverage
*
Medical Payments Coverage
$1,000
$2,000
$5,000
$10,000
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 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 PHYSICAL 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
Face Amount $250,000, $500,000 or whatever amount preferred
*
Term Policy Years
*
Term Policy Years
10 Years
15 Years
20 Years
30 Years
Business Insurance
Do You Currently Have Business Insurance?
Do You Currently Have Business Insurance?
No
Yes
Current Carrier
Do you have a current business insurance declaration page?
Do you have a current business insurance declaration page?
No
Yes
Please upload it here:
Drop files here or
Select files
Max. file size: 59 MB.
Effective Date
*
Name of Owner
*
Owner Mailing Address
*
Owner Cell Phone
*
Owner Email
*
Additional Owner's Name (if applicable)
Additional Owner's Email (if applicable)
Name of Business
*
Business DBA
Business Address 1
*
Business Address 2
*
Business Address City
*
Business Address State
*
Business Address Zip
*
Business Phone
Website (if applicable)
Federal Tax ID or SSN
*
Business Entity (LLC, Corp, S-Corp, Sole Prop)
*
Type of Business (Brief Description)
*
Years in Business
*
Years Experience in the field
*
Gross Sales (est.)
*
Annual Payroll (est.)
*
Business Personal Property Coverage ($)
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)
*
Alarms (Local/Central/None) Fire
Burglar
Sprinkler System (0-100%)
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