Homeowners Insurance Application - NC

Contents Broad (HO4)

Application to:

Erie Insurance Company

100 Erie Insurance Place Erie, PA 16530
www.erieinsurance.com
The Applicant applies for insurance and represents the following to be true. Origin Date:
12/2020
Applicant Mailing Address Policy Period:
MILDRED C CROUCH 133 W FRANKLIN ST STE A220 12:01 A.M. Standard Time
CHAPEL HILL NC 27516-2525 12/01/2020 until 12/01/2021
Applicant Address
133 W FRANKLIN ST STE A220 Phone Policy Number:
CHAPEL HILL NC 27516-2525 Home (919) 971-0957 Q60-5116578
JACROUCH22@GMAIL.COM
County
Orange
Agent Contact Information Agent Information
(919) 571-0685 JJ1605
Fax (919) 571-0684 CAPITAL INS & FIN SERVICES INC
erie@capital-ins.com http://www.capital-ins.com

Residence Information
The dwelling described in this application is occupied by the Applicant as a primary residence.
Property insured is located at: 133 W FRANKLIN ST STE A220 CHAPEL HILL NC 27516-2525
Township/County/Indep. City: Orange
Distance to fire hydrant: 500 ft. Distance to fire department: 1 mile
Protection Class: 2 - CHAPEL HILL
Loss Settlement Information Applicable Deductibles
Personal Property
Policy Deductible $1,000
_X_Replacement Cost
___Actual Cash Value
Coverage Perils Information
Personal Property
_X_Comprehensive Perils
___Named Perils

Based upon the Loss Settlement and Coverage Perils selected, you
have chosen the Contents Broad (HO4) Policy.

PA0029NC-ESHHO4 08/14
Page 1 of 3
 ERIE Agent Applicant Policy No.
CAPITAL INS & FIN SERVICES INC MILDRED C CROUCH Q60-5116578
(919) 571-0685
http://www.capital-ins.com
Coverage Information
Section I - Property Protection Premium
Amount of Insurance:Personal Property: $20,000 Loss of Use: $4,000 $135
i

Section II - Home and Family Liability Protection

Amount of Insurance:Personal Liability: $300,000 each occurrence Medical Payments to Others: $1,000 each person

Applicable Discounts and Selected Endorsements

Advanced Quote Discount INCL

Payment Information
Total Annual Policy Premium $135.00
Payment $0.00
Balance $135.00
Payment Plan* Annual
*Any installment charges that apply under the payment plan selected are paid to Erie Indemnity Company.
Warning: An incorrect answer, intentional or not, to any information below may jeopardize the acceptance of this application.
Does the Applicant currently have Homeowners Insurance with ERIE? No
Does the Applicant desire Water Backup or Sump Overflow coverage? No
A: Is the dwelling at the indicated property location currently occupied by you as your primary residence? Yes
B: Have you ever had similar insurance on this property or any other property during the past 5 years? Yes
If ’Yes’ list Company: Other
C: Except for nonpayment of premium, has any company declined, cancelled or refused to renew any similar No
insurance?
D: Has Applicant had any losses or claims of any nature, whether insured or not, such as fire, windstorm, theft, No
liability, etc. on this or any other property during the last 5 years?
E: Are there animals, including farm animals or pets on the premises? No
F: Is Applicant conducting any business or occupational pursuits at the premises? No

PA0029NC-ESHHO4 08/14 Page 2 of 3

 ERIE Agent Applicant Policy No.
CAPITAL INS & FIN SERVICES INC MILDRED C CROUCH Q60-5116578
(919) 571-0685
http://www.capital-ins.com

NOTICE OF INSURANCE INFORMATION PRACTICES:

As part of our procedure for processing your insurance application, personal information such as a credit report, prior insurance claims
report, and/or motor vehicle record may be obtained concerning you and other individuals proposed for coverage.

We may, in connection with this application for insurance, review your credit report or obtain or use a credit based insurance score
based on the information contained in that credit report. We may use a third party in connection with the development of your insurance
score.

No information from our files will be given to anyone without your written consent, except as allowed by law in order to conduct our
business.

You have the right to know the kind of information we have in your file, to have access to that information, and to request correction of
information you believe is inaccurate.

We will provide a more detailed description of our information practices, if you so request.

APPLICANT(S) PLEASE READ:

ANY PERSON WHO KNOWINGLY FILES AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION, MAY BE SUBJECT TO CRIMINAL AND/OR CIVIL PENALTIES.

APPLICANT TO ERIE INSURANCE COMPANY SIGN HERE:

I certify that I have given true and complete answers to the questions in this application.
I have been given notice of the NOTICE OF INSURANCE INFORMATION PRACTICES.
e-Signed by MILDRED CROUCH
Applicant signature:________________________________________________________
on 2020-12-02 20:07:51 GMT Date:______________________________
WARNING: You may submit risks that have been previously cancelled or declined or not renewed by ERIE or some other
insurer for our consideration. However, you may not bind such a risk until after our investigation is complete and we find the
risk acceptable.

e-Signed by Suzanne Abreu

Agent Signature:__________________________________________________________
on 2020-12-02 14:14:57 GMT Date:______________________________

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