Professional Offices - Hutch

Professional Offices – 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:

Number of claims:

Claim(s) details:

Description of operation:

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:

General

Total building square footage:

(not UPP eligible if exceeds 50,000 sq. ft. for tenant occupied office or exceeds 150,000 sq. ft. for owner occupied office.)

List occupants / percentage occupied:

Lessors risk office space?

Any commercial cooking?

Written lease agreements in place?

Proof of insurance (COI) obtained?

Percent occupied:

(less than 70% underwriter approval)

Fire and Burglary Protection

Is there a burglar alarm?

Monitored by central station?

(Required if controlled substances kept on site)

Is there a fire alarm?

Monitored by central station?

Automatic Sprinkler System?

If yes, provide annual service date.

Property Protection

ISO public protection class:

(PPC 10 needs underwriter approval)

Cameras?

(recorded)

Emergency lighting?

Fire extinguishers?

If yes, provide last service date

General Premises

Hours of operation?

Walking surfaces in good condition?

Housekeeping good?

Snow removal program in place?

Place for cigarettes?

Smoke-free building?

Service maintenance program?

Incident form for slips, trips and falls?

Building

Year built:

Construction type:

Total Square footage:

Number of stories:

Building value:

Contents value:

Roof age:

Updates:

Plumbing age:

Updates:

HVAC age:

Updates:

Any observed water leaks?

Mechanical rooms free of clutter and accessible?

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?

Workers’ Compensation

Material handling / back injury prevention program?

Safe Practices / Animal handling training?

Are exit doors easily accessible and unblocked?

Expert modification factor:

Expert modification date:

Sole proprietor / Partners coverage?

Corporate officer coverage?

List

Class code #:

Payroll =

Average length of employment:

Safety:

Safety meetings

Lifting training

Forklift training

PPE training

(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.

Liability

Med Pay

Um / Uim

Comp

Coll

List

Year

Make

Model

VIN