Agency Service Form – My Erie Insurance

Agency Name(Required)
Main Agency Code(Required)
Agency Or Agency Personnel Email(Required)
Agency Representative Entering Service Request(Required)
First Last
Medium Of Request
- Email
- Phone Call – To Agency
- Phone Call – Agent Mobile
- Text Or SMS – Agency
- Text Or SMS – Agent Mobile
- Mail
- In Person – Off Site
- In Person – Office
Who Is Requesting The Policy Service?(Required)
- Client
- Insurance Carrier
- 3rd Party (Dealership – Mortgage Company – Etc)
Insurance Carrier Name(Required)
Name Of Requestor(Required)
What Company Are You With? (Name Of Requestor's Company)(Required)
Is This A Personal Insured Or Business Insured?(Required)
- Personal
- Business
Type Of Request(Required)
- Endorsement
- Certificate Or Proof Of Insurance
- Other
What Is Our Insured's Name? (Personal)
First Last
What Is Our Insured's Name? (Business)(Required)
Client's Email
Personal Policy Types Affected
- Personal – Auto
- Personal – Home – Condo – Renters – Etc
- Personal – Umbrella
- Personal – Other
Personal Auto – Change Types
- Add Vehicle
- Add Driver
- All Other
Endorsement Note – Personal Auto – Add Vehicle
Insurance Carrier: Effective Date: Policy Number: Add The Following Year: Make: Model: VIN: Usage: Pleasure | To/From Work < 10 Miles | To/From Work > 10 Miles | Business Annual Mileage: Primary Driver: Comprehensive: None | $0 | $100 | $250 | $500 | $1,000 Collision: None | $100 | $250 | $500 | $500 | $1,000 Rental Reimbursement: None | $15/$450 | $30/$900 | $50/$1,500 Towing & Labor: None | $25 | $50 | $100 Repair/Replacement: Yes | No Is There Loan? If So, Loss Payee Information
Endorsement Note – Personal Auto – Add Driver
Insurance Carrier: Effective Date: Policy Number: Add The Following Name: Date Of Birth: Driver's License/Permit Number: Date Licensed: Vehicle Assigned To: Primary Or Occasional Operation:
Endorsement Note – Personal Auto – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Personal – Home – Condo – Renters – Etc
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Personal – Unbrella
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Personal – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Business Policy Types Affected
- Business – Business Owners – GL – Property
- Business – Auto
- Business – Workers Compensation
- Business – Umbrella
- Business – Other
Business – Business Owners – GL – Property – Change Types
- Add Location – Building
- Add Equipment
- All Other
Endorsement Note – Business – Business Owners – Property
Insurance Carrier: Effective Date: Policy Number: Address: Year Built: Construction Type: Frame | Masonry Veneer | Joisted Masonry | Masonry Non-Combustible # of Stories: Square Footage: Year Of Updates (if any) Roof: Plumbing: Electrical: HVAC: Is There A Loan/Lien? If So, Lienholder Information:
Endorsement Note – Business – Business Owners – Equipment
Insurance Carrier: Effective Date: Policy Number: Year: Make: Model: Serial Number: Value: Is There A Loan/Lien? If So, Lienholder Information:
Endorsement Note – Business – Business Owners – All Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instructions For Request:
Business Auto – Change Types
- Add Vehicle
- Add Driver
- All Other
Endorsement Note – Business Auto – Add Vehicle
Insurance Carrier: Effective Date: Policy Number: Add The Following Year: Make: Model: VIN: Gross Vehicle Weight (GVW): Radius Of Operations: Customized Equipment: If Yes, What Is It, And What Value Liability Limit: Use Existing Policy Limits Medical Payment: Check Policy & Add If Present On Any Other Vehicles Comprehensive: None | $0 | $100 | $250 | $500 | $1,000 Collision: None | $100 | $250 | $500 | $500 | $1,000 Rental Reimbursement: Check If Eligible & Add If On Other Policy Vehicles Towing & Labor: Check If Eligible & Add If On Other Policy Vehicles UM/UIM: Use Existing Policy Limits Is There Loan? If So, Loss Payee Information
Endorsement Note – Business Auto – Add Driver
Insurance Carrier: Effective Date: Policy Number: Insurance Carrier: Policy Number: Add The Following Name: Date Of Birth: Driver's License Number:
Endorsement Note – Business Auto – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Business – Workers Compensation
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Business – Commercial Umbrella
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Business – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Client Information
You will want to say something like “while I pull up your account, let me make sure we have all of your records up to date” Start the conversation by confirming/updating basic contact information (if you are speaking with the client) | Open up your management system and/or your CRM so that you can verify the information below.
Insured Name(Required)
First Last
Is This For Your Personal Insurance Of Business(Required)
- Personal
- Business
What's The Name Of Your Business?
Email Address(Required)

Is {enter email} still the best email address for you? If there is no email on file..”I don’t see that we have an email on file for you, what’s the best email address?”
What Is The Best Phone Number For You?(Required)
Make sure you find out the best phone number & phone type
Is This Your Cell, Home, Or Work Phone?(Required)
- Cell Phone
- Home Phone
- Work Number
What Is Your Cell Phone Number?
We Will Text You About That Status Of Your Policy Requests From Time To Time, Is This Ok?(Required)
- Yes
- No
We Will Text You About That Status Of Your Policy Requests From Time To Time, Is This Ok?(Required)
- Yes
- No
Is The Address Still The Same?(Required)
- Yes
- No
- No Address Shows In System
Is Your address still {insert street name or PO Box that shows in Nowcerts}
Address(Required)
Street Address City State ZIP Code
Would you like me to update your address on all of your policies?(Required)
- Yes
- No
Please make sure to ask if this is just a mailing address update or location & mailing address change
Service Information
You should say something like this…”Alright, I’ve got you pulled up in my system…what can I help you with?” We are now going to move to the policy service request. Remember, you can NOT suggest or discuss coverage unless you are licensed
INTERNAL NOTE – Select Personal Or Business(Required)
- Personal
- Business
Type Of Request(Required)
- Endorsement
- Certificate Or Proof Of Insurance
- Other
INTERNAL NOTE – Is This Is Cancellation Request?(Required)
- No (insured is not cancelling anything)
- Yes – One Policy
- Yes – All Policies
Make sure to confirm whether or not the insured wants to cancel ALL Policies, just one policy, or no cancellations
Why Are You Cancelling?(Required)
- Insurance No Longer Needed
- Moving To Another Provider (Pricing Related)
- Moving To Another Provider (Unhappy With Agency)
- Moving Out Of State
- Moving To Another Part Of The State
- Other
What Carrier Are You Moving To?(Required)
Why Are You Cancelling?(Required)
Would Love To Know How We Can Be Better, Would You Mind Letting Me Know A Little More About Why You Are Leaving?
What Is Your New Address?
Street Address City State ZIP Code
Personal Policy Types Affected
- Personal – Auto
- Personal – Home – Condo – Renters – Etc
- Personal – Umbrella
- Personal – Other
Personal Auto – Change Types
- Add Vehicle
- Add Driver
- All Other
Endorsement Note – Personal Auto – Add Vehicle
Insurance Carrier: Effective Date: Policy Number: Add The Following Year: Make: Model: VIN: Usage: Pleasure | To/From Work < 10 Miles | To/From Work > 10 Miles | Business Annual Mileage: Primary Driver: Comprehensive: None | $0 | $100 | $250 | $500 | $1,000 Collision: None | $100 | $250 | $500 | $500 | $1,000 Rental Reimbursement: None | $15/$450 | $30/$900 | $50/$1,500 Towing & Labor: None | $25 | $50 | $100 Repair/Replacement: Yes | No Is There Loan? If So, Loss Payee Information
Endorsement Note – Personal Auto – Add Driver
Insurance Carrier: Effective Date: Policy Number: Add The Following Name: Date Of Birth: Driver's License/Permit Number: Date Licensed: Vehicle Assigned To: Primary Or Occasional Operation:
Endorsement Note – Personal Auto – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Personal – Home – Condo – Renters – Etc
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Personal – Unbrella
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Personal – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Business Policy Types Affected
- Business – Business Owners – GL – Property
- Business – Auto
- Business – Workers Compensation
- Business – Umbrella
- Business – Other
Business – Business Owners – GL – Property – Change Types
- Add Location – Building
- Add Equipment
- All Other
Endorsement Note – Business – Business Owners – Property
Insurance Carrier: Effective Date: Policy Number: Address: Year Built: Construction Type: Frame | Masonry Veneer | Joisted Masonry | Masonry Non-Combustible # of Stories: Square Footage: Year Of Updates (if any) Roof: Plumbing: Electrical: HVAC: Is There A Loan/Lien? If So, Lienholder Information:
Endorsement Note – Business – Business Owners – Equipment
Insurance Carrier: Effective Date: Policy Number: Year: Make: Model: Serial Number: Value: Is There A Loan/Lien? If So, Lienholder Information:
Endorsement Note – Business – Business Owners – Equipment
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instructions For Request:
Business Auto – Change Types
- Add Vehicle
- Add Driver
- All Other
Endorsement Note – Business Auto – Add Vehicle
Insurance Carrier: Effective Date: Policy Number: Add The Following Year: Make: Model: VIN: Gross Vehicle Weight (GVW): Radius Of Operations: Customized Equipment: If Yes, What Is It, And What Value Liability Limit: Use Existing Policy Limits Medical Payment: Check Policy & Add If Present On Any Other Vehicles Comprehensive: None | $0 | $100 | $250 | $500 | $1,000 Collision: None | $100 | $250 | $500 | $500 | $1,000 Rental Reimbursement: Check If Eligible & Add If On Other Policy Vehicles Towing & Labor: Check If Eligible & Add If On Other Policy Vehicles UM/UIM: Use Existing Policy Limits Is There Loan? If So, Loss Payee Information
Endorsement Note – Business Auto – Add Driver
Insurance Carrier: Effective Date: Policy Number: Insurance Carrier: Policy Number: Add The Following Name: Date Of Birth: Driver's License Number:
Endorsement Note – Business Auto – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Business – Workers Compensation
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Business – Commercial Umbrella
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Endorsement Note – Business – Other
Insurance Carrier: Effective Date: Policy Number: Actual Notes/Instruction For Request:
Certificate Holder Information
Business/Certificate Holder Name(Required)
Contact Person
First Last
Address(Required)
Street Address City State ZIP Code
Phone
Certificate Holder Email
Certificate Information
Does COI Holder Need To Be Additional insured?(Required)
- No
- Yes
Details for Additional Insured(Required)
Does COI Holder Need To Be Listed As Loss/Payee(Required)
- Yes
- No
Does COI Holder Need A Waiver of Subrogation – If So, On Which Policies(Required)
- Yes
- No
Is There Special Verbiage The Certificate Holder Requires?(Required)
- Yes
- No
Special Verbiage(Required)
Upload | Attach Any Relevant Files Here
Drop files here or

Max. file size: 12 GB.
Misc Notes – Section
This Is A "Catch All" Section – If you need to notate anything that doesn't fit elsewhere – please enter here
Upload Misc Files
Drop files here or

Max. file size: 12 GB.

Client Information

Service Information

Certificate Holder Information

Certificate Information

Misc Notes – Section

This website is not affiliated with Erie Insurance.