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Own or Rent or Other?
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How Many Years?
Previous Address
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Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Driver's License #
Age or Year When First Licensed
Have you ever had your drivers license or drivers' privileges revoked or suspended?
Yes
No
Prior License
Highest Level of Education
Date of Birth
MM slash DD slash YYYY
Single / Married / Divorced / Widowed
Single
Married
Divorced
Widowed
Any One Else in the Household?
Yes
No
Relationship to you?
Any Children of Age to Drive?
Yes
No
Do they have their own car?
Yes
No
Do they have their own insurance?
Yes
No
In the past three years have you had any comprehensive losses? (deer claims, theft, fire)
Yes
No
What were they?
In the past three years, regardless of fault, have you been involved in an accident or have you reported a claim to an insurance company?
Yes
No
What were they?
In the past three years have you received a ticket for speeding or any other violation?
Yes
No
If speeding, speed limit/actual speed
Other:
Ever been arrested for any reason?
Yes
No
Occupation/Student
Employer/School
Do you have any physical or mental impairment or disability that would affect your ability to drive?
Yes
No
Prior Coverage Info
Prior Carrier
Renewal Date
MM slash DD slash YYYY
Premium
Had an auto insurance refused, cancelled, or expired in the last 3 years?
Yes
No
Have you ever been excluded or restricted on any auto policy?
Yes
No
Company, policy, date and reason
In the past three years have you ever been required to file evidence of financial responsibility?
Yes
No
FOR MARYLAND- has any driver refused to submit to a chemical test or been given probation before judgement for an alcohol or other vehicle code in the past three years?
Yes
No
Other Drivers
(who else drives the vehicles being listed on the policy?)
First Name
Last Name
Phone
Relationship
Date of Birth
MM slash DD slash YYYY
Drivers License #
When Licensed
Single / Married / Divorced / Widowed
Single
Married
Divorced
Widowed
Ever been Excluded as a Driver
Yes
No
Any Accidents, Claims, Violations
Yes
No
Occupation/Student
Employer/School
If Retired - From Where?
Military?
Yes
No
Notes / Additional Details
Vehicle Details
Year
Make
Model
Driver
Vin#
Owned How Long?
If New - Where Purchased?
Price Paid?
Lien Holder
Deductibles: Comp
Deductibles: Coll
Used for
Pleasure
Work / School
Days per Week
How Many Miles One Way?
How Many Miles Per Year?
Any Existing Damage?
How Is Vehicle Titled?
Current Coverage Amounts
Liability / Full Bodily
State Minimum Liability Coverage
Yes
No
Property Damage
15/1,000,000
Personal Protection (PIP)
Medical 2500 - 10,000
Comprehensive Deductible
Collision Deductible
Road Service? (covers Towing, Locked Doors, Repair Flat)
Yes
No
Transportation Exp (Rental Coverage)?
Yes
No
Car Rental Classes
Class 1 INCLUDED in Comp- Compact Sedan
Class 2 - $20.00 per day - Traditional Sedan
Class 3 - $30.00 per day- Smal SUV/Pickup
Class 4- $40.00 per day- Minivan/Midsize SUV
Class 5- $50.00 per day- Luxury Sedan/Large SUV
Endorsements
Erie Auto Plus
New Auto Security Coverage
Erie Auto Plus and New Auto Security Coverage
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301-334-3968
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