Multipurpose Claims Form – My Erie Insurance

Agency Name*
Main Agency Code*
Agency Or Agency Personnel Email*
Agency Representative Entering Claim*
First Last
Who Is Initiating The Claim?*
- Insured (Or Relative Of Insurance)
- Third Party (Not Our Insured)
Name Of Person Filing Claim
First Last
Phone Number Of Person Filing Claim
Email Of Person Filing Claim
More Information About Person Filing Claim
Is This A Personal Or Business Claim?*
- Personal
- Business
What Type Of Personal Claim?*
- Auto
- Home And Property
- Personal Liability
- Personal – Other
What Type Of Business Claim?*
- Business Auto
- Commercial Property
- Commercial Liability
- Workers Compensation
Insured Name*
First Last
Business Name*
Primary Business Contact*
First Last
Mobile Phone*
Is It Ok For The Carrier To Text Regarding Your Claim?
Email
Policy Number (If Known)
Personal Auto Insurance Claim Information
What Best Describes The Cause Of The Incident*
- My Vehicle Was In An Accident
- An Animal Damaged My Vehicle
- Windshield | Window Damage
- Weather Damaged My Vehicle
- Flood
- I Was Injured (No Damage To My Vehicle)
- My Vehicle, Or Its Content, Was Stolen Or Vandalized
- Towing Reimbursement
- Something Else Happened To My Vehicle
What Caused The Damage To Your Vehicle?
- Another Moving Car | Motorcycle | Train | Bus
- A Parked Car Of Fixed Object
- An Animal
- A Pedestrian
- A Bike
How Were You Injured?
- While Entering Or Exiting Vehicle
- While A Passenger In Someone Else’s Vehicle
- As A Pedestrian
- While Working On Vehicle
How Was Your Vehicle Damaged?
- Something Was Stolen From My Vehicle
- My Vehicle Was Stolen
- My Vehicle Was Vandalized
- My Vehicle Was Set On Fire
Approximate Date Of Loss
MM slash DD slash YYYY
Approximate Time Of Loss

: Hours

Minutes

AM/PM
Where Did The Incident Occur?
Street Address City State ZIP Code
Are You Still At The Scene?
- Yes
- No
Was Anyone Injured?
- Yes
- No
- I’m Not Sure
Who Was Injured? (Include Names, Injuries, Contact Info, etc)
What Type Of Accident Was it
- I was rear-ended
- I rear-ended someone
- I was in an accident with other moving cars
What Vehicle(s) Were Involved In The Incident (Your Vehicle(s))
Supply The Following Information: YEAR MAKE MODEL VIN (Vehicle Identification Number)
Brief Summary Of Incident
Please supply us with some details about the incident
Police Information (Optional)
Police Department | Official’s Name | Report Number
Misc Information
Police Department | Official’s Name | Report Number
Upload Any Files
Drop files here or

Max. file size: 12 GB.
Homeowners And Personal Property Insurance Claim Information
What Best Describes The Cause Of The Incident*
- My Property Was Damaged By Fire Or Water
- My Property Was Damaged By An Act Of Nature
- My Property Was Lost Or Was Stolen In A Criminal Act
- My Property Was Damaged By Another Cause
- Someone Is Making A Claim Against Me (Liability Loss)
- Something Else Happened
What Caused The Damage
- Fire Or Smoke
- Water From Sewer Or Drain Backup
- Rupturing And/Or Leaking Of Plumbing Pipes
- Other Water Damage Or Mold
What Caused The Damage
- Wind
- Hail
- Flood
- Weight Of Ice or Snow
- Lightning or Power Surge
- Tree Debris
- Ground Movement
What Caused The Damage
- Theft
- Vandalism
- Identity Theft
What Caused The Damage
- Food Spoilage
- Vehicle
- Flood
- Mechanical Or Electrical Breakdown
- Explosion
- Collapse
- Pollution, Bio-Hazard, or Toxic Materials
- Falling Objects
What Caused The Damage
- Injury To Others Or Damage To Their Property
- Injury Caused By An Animal
- Personal & Advertising Liability (Slander / Libel)
- Professional Liability
- Liquor Liability
- Assault Or Battery
Approximate Date Of Loss
MM slash DD slash YYYY
Approximate Time Of Loss

: Hours

Minutes

AM/PM
Where Did The Incident Occur?
Street Address City State ZIP Code
Damage Details (Enter At Least One)
- Home | Dwelling
- Other Structures
- Personal Property
- Someone Else’s Property
- Someone Else (Personal Injury)
Where Did The Damage Occur? (Select All That Apply)
- Exterior
- Interior
- Interior and Exterior
What Exterior Damage Occurred?
- Roof
- Windows
- Doors
- Exterior Walls
- Gutters
- AC | Furnace
- Other
How Many Stories Are In The Home | Dwelling?
- 1
- 2
- 3+
What Interior Damage Occurred?
- Ceiling
- Floors
- Walls
- Other
How Many Rooms Are Affected?
- 1
- 2
- 3
- 4+
Is The Home | Building Safe To Live In?
- Yes
- No
What Other Structures Were Damaged?
- Detached Garage
- Shed
- Fence
- Pool
- Other
Please Provide Details About What Was Damaged
Please Provide Details About What Was Damaged
Details (Please Give Details As To What Happened)
Upload Any Files
Drop files here or

Max. file size: 12 GB.
Personal Liability Insurance Claim Information
Date Of Loss
MM slash DD slash YYYY
Approximate Time Of Loss

: Hours

Minutes

AM/PM
Location Of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Describe Location Of Loss If Not At Specific Street Address
Were The Police Or Fire Department Contacted?
- Yes
- No
Report Number
Estimated Amount Of Entire Loss (If Possible)
Description Of Loss & Damage (Details)
Upload Any Files
Drop files here or

Max. file size: 12 GB.
Business Auto Insurance Claim Information
Date Of Loss
MM slash DD slash YYYY
Approximate Time Of Loss

: Hours

Minutes

AM/PM
Location Of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Describe Location Of Loss If Not At Specific Street Address
Were The Police Or Fire Department Contacted?
- Yes
- No
Report Number
What Kind Of Loss Is This?*
- My Vehicle Was In An Accident
- An Animal Damaged My Vehicle
- Windshield | Window Damage
- Weather Damaged My Vehicle
- I Was Injured (No Damage To My Vehicle)
- My Vehicle, Or Its Content, Was Stolen Or Vandalized
- Towing Reimbursement
- Something Else Happened To My Vehicle
Estimated Amount Of Entire Loss (If Possible)
Description Of Loss & Damage (Details)
Insured Vehicle Information
Year
Make
Model
Vehicle Identification Number
Body Type
- Private Passenger
- Truck
- Trailer
- Camper
Plate Number
Registration State
State
Vehicle Owner – Same As Named Insured?
- Yes
- No
Owner's Name & Address & Contact Info (Phone | Email)
Driver Is Same As First Named Insured From Above?
- Yes
- No
Driver's Name
First Last
Driver's Phone
Driver's Address
Street Address City State ZIP Code
Relation To Insured
- Family Member
- Employee
Driver's Date Of Birth
MM slash DD slash YYYY
Driver's License Number
State Of License
State
Purpose Of The Vehicle's Use
- Normal Daily Use
- Pleasure
- Business Use
Did The Driver Have Permission To Use The Vehicle?
- Yes
- No
Describe The Damage To The Insured Vehicle
Estimated Amount Of Damage To Insured Vehicle?
Where (Location) & When Can The Insured Vehicle Be Seen?
Other Vehicle | Property Damage Information
Was Another Vehicle(s) | Property | Person Damaged/Injured In The Accident (Check All That Apply)
- Vehicle(s)
- Property
- Person(s)
- No Other Vehicles | Property | Persons Damaged/Injured
Other Vehicle(s) Information
Please Give Year | Make | Model of all other vehicles involved in the accident
Damaged Property Information
Describe Property That Was Damaged
Other Vehicle | Property Insured?
- Yes
- No
- I Don’t Know
Insurance Carrier
Policy Number
Property | Vehicle Owner's Information
Include Name | Address | Phone
Vehicle Driver's Information (If Different Than Owner)
Include Name | Address | Phone
Describe Damage | Injuries
Estimated Amount of Vehicle | Property Damage
Where Can The Damage Be Seen?
Injured Party Information
Were Any Injuries Sustained?
- Yes
- No
How Many People Were Injured?
- 1
- 2
- 3
- 4+
Name Of 1st Injured Party
First Last
Address Of 1st Injured Party
Street Address City State ZIP Code
Phone Of 1st Injured Party
Where Was The 1st Injured Party
- Pedestrian
- Insured’s Vehicle
- Other Vehicle
Age Of 1st Injured Party
Description of 1st Injured Party's Injuries
Name Of 2nd Injured Party
First Last
Address Of 2nd Injured Party
Street Address City State ZIP Code
Phone Of 2nd Injured Party
Where Was The 2nd Injured Party
- Pedestrian
- Insured’s Vehicle
- Other Vehicle
Age Of 2nd Injured Party
Description of 2nd Injured Party's Injuries
Name Of 3rd Injured Party
First Last
Address Of 3rd Injured Party
Street Address City State ZIP Code
Phone Of 3rd Injured Party
Where Was The 3rd Injured Party
- Pedestrian
- Insured’s Vehicle
- Other Vehicle
Age Of 3rd Injured Party
Description of 3rd Injured Party's Injuries
Name Of 4th Injured Party
First Last
Address Of 4th Injured Party
Street Address City State ZIP Code
Phone Of 4th Injured Party
Where Was The 4th Injured Party
- Pedestrian
- Insured’s Vehicle
- Other Vehicle
Age Of 4th Injured Party
Description of 4th Injured Party's Injuries
Upload Any Files
Drop files here or

Max. file size: 12 GB.
Commercial Property Claim Information
Date Of Loss
MM slash DD slash YYYY
Approximate Time Of Loss

: Hours

Minutes

AM/PM
Location Of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Describe Location Of Loss If Not At Specific Street Address
Were The Police Or Fire Department Contacted?
- Yes
- No
Report Number
What Kind Of Loss Is This?
- Fire
- Theft
- Lightning
- Hail
- Flood
- Wind
Estimated Amount Of Entire Loss (If Possible)
Description Of Loss & Damage (Details)
Upload Any Files
Drop files here or

Max. file size: 12 GB.
Commercial Liability Claim Information
Date Of Loss
MM slash DD slash YYYY
Approximate Time Of Loss

: Hours

Minutes

AM/PM
Location Of Loss
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Describe Location Of Loss If Not At Specific Street Address
Were The Police Or Fire Department Contacted?
- Yes
- No
Report Number
Estimated Amount Of Entire Loss (If Possible)
Description Of Loss & Damage (Details)
Upload Any Files
Drop files here or

Max. file size: 12 GB.
Workers Compensation Claim Information

Personal Auto Insurance Claim Information

Homeowners And Personal Property Insurance Claim Information

Personal Liability Insurance Claim Information

Business Auto Insurance Claim Information

Insured Vehicle Information

Other Vehicle | Property Damage Information

Injured Party Information

Commercial Property Claim Information

Commercial Liability Claim Information

Workers Compensation Claim Information

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