Commercial Quote – Insurance Forms

Information is used solely for the purpose of quoting the insurance policies you request.
Select The Policies You Want Quoted*
More Policies Could Mean More Discounts!
- Commercial Auto
- Commercial Umbrella
- Cyber Liability
- Directors and Officers
- General Liability
- Professional Liability
- Property
- Workers Comp
- Other

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General Info
Business & Contact Info
Business Name*

Legal name of your business.
Contact Name*
First Last
Physical Address*
Can’t be a PO Box

Street Address Address Line 2 City State ZIP Code
Mailing Address
Same as Physical

Street Address Address Line 2 City State ZIP Code

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General Info
Operation Info
Choose the description that best fits your primary operation*
Start typing a keyword to filter the options.
Describe your business*
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Class Data
Class Data is provided as a possible guide based on user submitted data. Accuracy is not guaranteed.
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SIC Code
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SIC Industry
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Industry
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ISO GL Code
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GL Basis symbol
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GL Premium Basis
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NCCI Default WC Code (may differ by state)
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PA WC Code
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Erie Class Data
Class Data is provided as a possible guide based on user submitted data. Accuracy is not guaranteed.
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Erie UPP or UFX Liability Code (Not eligible if blank)

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General Info
Business History
Number of Years in Business?*
Please enter a number from 0 to 100.
Number of Years Experience?*
Please enter a number from 0 to 100.
Are you or were you an owner in any other businesses?*
- No
- I am part of another company that is separate from this one.
- I had a prior company that is no longer operating
Describe other owned entities (current or prior) and their relationship to this business.*

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Workers Comp
Do you regularly work more than 10ft above the ground or floor?*
Maximum Height above the ground or floor?*
(in Feet)
Do you use subcontractors that have their own insurance?*
(Must have GL & WC)
Amount paid annually to fully insured subs*
How many years have you had prior WC coverage?*
Who is your current WC insurance company?*
Do you have any non-compliant audits or unpaid premiums owed to an insurance company for this business or other businesses?*
- No
- Yes
- Notes
Notes

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Provide a Name or Description for this property (Office, Warehouse, etc.)
	Edit Delete
There are no Entries.

Maximum number of entries reached.

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Professional Liability (E&O)
Describe the services your firm provides in as much detail as you can*
List the number of people and total payroll for each professional service rendered.
Professional Service or Title # of People Total Payroll

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Commercial Auto
Vehicle & Driver Info*
You can either upload this information if you have it from a prior policy or add each driver and vehicle individually.
- Upload Vehicle List
- Upload Driver List
- Add Vehicle(s)
- Add Driver(s)
Upload Auto or Driver information*
Drop files here or

Max. file size: 64 MB.
What type of vehicle(s) do you need to add?*
Standard vehicles include cars, SUV’s, pickup trucks, etc. Non-Standard vehicles include motorcycles, box trucks, ATV’s, campers, RV’s, trailers, etc.
- Standard
- Non-Standard

Standard Vehicles

Year	Make	Model
			Edit Delete
There are no Vehicles.

Maximum number of vehicles reached.

Non-Standard Vehicles

Year	Make	Model or Description
			Edit Delete
There are no Other Vehicle Types.

Maximum number of other vehicle types reached.

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Claims
Have you ever had a claim for this or any other business you owned or managed?*
- No
- Yes
How many claims have you had in the last 3 years?*
What is the estimated total that was paid out on those claims?*
Briefly describe the claim circumstances*

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Final Details
Do you use a Social Security, Tax ID number or a Federal EIN?*
SSN, Tax ID, or EIN*

If you have an EIN but don’t have it with you, enter all “9”s.
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Federal EIN
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Social Security or Individual Tax ID
What type of Entity is your business?*
How many owners are there in the business?*
Anything else you'd like us to know? (Optional)
We like helping people, not robots. Please check the box to confirm you're a human.
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Source
(Agent Only)
- Internal
Internal Use Only (Click to expand)
Was this customer referred by anyone?
Enter the name of the person that referred this customer. Skip if No.
First Last
Delivery Email
If you want to send this prospect to a specific Agent, enter their email.
Name of Submitter*
Enter your name so the Agent receiving this prospect knows who spoke to the customer.
First Last
Agent ID (Optional)
Enter the Agent ID of the submitting Agent. Used for tracking in management systems.
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Agency Account Profile
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agency_id
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user_id
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Agency Name
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Agent Phone
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Agent Name
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Agent Email
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Commercial Lead Email
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Website
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Agency Mgmt System
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Agency Website Maintenance Contact
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Integration 3
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Source
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keyword

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Property Coverage
What type of property coverage do you need?
- Building
- Business Property
- Tools & Equipment
- Builders Risk
- Other
Building - Coverage for a structural building (Examples - Offices, Retail Shops, Warehouses, etc.)
Business Property - Contents and equipment stored at your business location (Example - Office Equipment, Inventory, etc.)
Tools & Equipment - Covers equipment used primarily away from the business location. (Example - An air compressor taken and used at job sites)
Builders Risk - Protects a structure while it’s being built or renovated.

Provide a Name or Description for this property (Office, Warehouse, etc.)*

If adding multiple properties or locations, each will be listed separately. Use this description to identify which building is which in your quote.
- Check if same as Mailing Address
Location Address*
Cannot be a PO Box.

Street Address Address Line 2 City State ZIP Code
Ownership*

Builders Risk
Select the description below that applies to you.*
- I'm the property owner
- I'm the general contractor
- I'm both the owner and general contractor
Name of General Contractor*
Is this a new build or renovation?*
- New Build
- Renovation
Total Cost of Build (Not Including Land)*
Existing Value of Structure (pre-renovation)*
Renovation Amount*
Deductible*
How long is this project expected to take?*
Total Square Footage of Project*