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Manufacturers Survey – Hutch

Business

Business name:

Legal entity:

Number of employees:

Contact name:

First Last

Phone:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other location(s):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:

Website / Social Media:

Annual sales:

Annual payroll:

Federal tax ID number:

Franchise:

Current carrier:

Years with current carrier:

Policy expiration date:

MM slash DD slash YYYY

Number of claims:

Claim(s) details:

Underwriting

Has the Applicant ever been canceled (incl. nonpay) or refused insurance of any kind by ERIE or any other insurance carrier?

If yes, please explain:

Has the Applicant filed for bankruptcy in the past 5 years?

If yes, please explain:

Property

Blanket

Deductible amount:

Coinsurance amount:

Replacement cost value:

Actual cash value:

Building value:

BPP / Contents:

Additional Property (signs, lights, clocks, fences, playgrounds, etc.)

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County:

Construction type:

Year built:

Year of roof:

Total square footage:

Your square footage:

List other tenants:

Sewer / Drain:

Money & Securities:

Tools off premises:

Include enhancement endorsement

Premises Exposures

Smoke Alarms:

Fire Alarm:

Burglar Alarm:

Fire Extinguishers:

Sprinklered:

Outside Lighting:

Lot Protection:

Year of roof:

Roof type:

Roof concerns:

Peeling / Flaking paint?

If yes, where?

Any Deterioration / Dry Rot?

If yes, where?

Foundation condition:

Walking surfaces:

Heating type:

Heating condition:

Age:

Electrical condition:

Age:

Overall Housekeeping?

General Liability Limit

Select one:

Umbrella?

Rating basis:

Sales / Receipts:

Payroll:

Data Breach liability:

Employee benefit liability:

Employment practices liability:

Deductible:

Number of Employees (full-time):

Number of Employees (part-time):

Third-party coverage?

General Information

Manufacturing or completed operations:

Job Shop

Component Parts

Design / Manufacturing

Raw Materials

Assembler

Installation

Re-manufacturing

Reverse Engineering

Repackaging / Relabeling

Servicing / Repairing

Leasing / Renting

Retail / Wholesale

Completed Equipment / Machinery

Contract Manufacturing

(check all that apply)

Product description:

Discontinued products:

In-house qualifications:

How are changes handled?

Inspection and testing procedures?

End Users & Industries served:

Where is product designed?

Customer design – Sign off on final design?

What quality control procedures are in place?

Any products or component parts imported directly from a foreign country?

If yes, please explain:

Any subcontracted operations?

If yes, please explain:

Record keeping for possible product recall?

If yes, please explain:

Transportation of product?

If yes, please explain:

High-hazard product attributes:

Agricultural Parts

Aerospace / Aircraft

Automotive Parts

Firearm Parts / Accessories

Food Products

Foreign Imported / Exported

Medical Device

Military / Government

Nanotechnology

Pharmaceutical

Toys / children’s products

(check all that apply)

Any exposure to dust-collection system type?

If yes, please explain:

Outfitted with spark detection and suppression?

If yes, please explain:

Any hazardous / flammable / explosive / caustic substances used in the insured’s process/product?

If yes, please explain:

Control procedures for these chemicals?

If yes, please explain:

Are tours of the facility ever conducted?

If yes, please explain:

Controls in place to protect public?

If yes, please explain:

Formal protective equipment requirements and machine guarding procedures?

If yes, please explain:

Any material handling devices?

(cranes, forklifts, automated rack storage, etc.)

If yes, please explain:

Any coating / painting operations?

If yes, please explain:

Is a written preventative maintenance plan in place for all production / process machinery and building systems?

If yes, please explain:

Do you manufacture, assemble, package or install products for others under their name or label?

If yes, please explain:

Are certificates of insurance obtained from major suppliers, contractors, or subcontractors?

If yes, please explain:

Do you ever service, repair, or build products you did not manufacture?

If yes, please explain:

Workers’ Compensation

Expert modification factor:

Expert modification date:

MM slash DD slash YYYY

Sole proprietor / Partners coverage?

Corporate officer coverage?

List

Class code #:

Payroll =

Average length of employment:

Safety:

(check all that apply)

Eye washing stations?

Autos

Auto used in business?

Autos titled to?

Hired / Non-owned?

Do your corporate officers maintain a personal auto policy?

If no, consider adding the corporate officers named coverage endorsement.

Included at direct primary

Limit is actual loss

Liability

Med Pay

Um / Uim

Comp

Coll

List

Year

Make

Model

VIN

Company

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