Quote

H. G. Ellis Agency, Inc.

For All Your Insurance Needs

Camden (315) 245-1270, Constantia (315) 623-7765, Cazenovia (315) 655-9066

Please bear with us while we get the electronic submission form set up. Please call or e-mail the closest office for quote or appointment.






			Get A Quote- Homeowners or Mobile Homeoweners






Oneida Lake/ Ft. Brewerton Chamber of Commerce



Camden Chamber of Commerce



Cazenovia Chamber of Commerce

To do a quote for you we will need all of the following information. Please collect the information and call or email the closest location to you to discuss.

To do a quote we are required by our companies to collect the applicants Social Security Number and Date of Birth. Companies use this information to verify claims and credit score in order to insure quote accuracy. If you do not wish to give this information out, your quote may not be accurate and it may negatively effect the quoted tier level. We do not sell or give out any of this information. Also, an incorrect or misrepresented answer to questions on this questionnaire can result in the denial of a policy or a claim. If you are not sure of anything, please let us know.

Applicant Name

Social Security Number

Applicant Name

Social Security Number


	Date of Birth

		Date of Birth

Property Address

Mailing Address

Phone Number

Email address

Preferred Method of contact


	or

County You Live In




	Distance from Fire Dept.

Responding Fire Department

Distance to Fire Hydrant

Number of years at current address

Prior address if < 3 years

Address(es) of any other residence or land owned, occupied or rented

Do you have current insurance?


	If yes, what company

Has any company cancelled or declined coverage? For what reason?

Any losses or claims at this or any other address? Please list dates and explain

Current coverage amount on:

Dwelling


	Personal Property

Other structures


	Liability/ Medical Payments

Deductible


	Premium


	Other

Year home was built

Number of families in home


	Purchase date & price


	Occupancy

Style and Number of Stories


	Square footage

Number of bedrooms


	Number of bathrooms

Other rooms

Type of Exterior Finish (vinyl/wood/ ect)

Method of Constructin (Frame/Masonry/ Ect)

Any part of the home mobile, manufactured or log? What

Fire Extinguisher


	Smoke Alarms


	Deadbolts


	Security System

Primary Heating Fuel


	Secondary Heat Source/Type

Roof Type (Shingle/Metal/Ect)

Year updates were completed on the:

Roof


Basement

Garage


	Electric


	Heating


	Plumbing


	If yes, is it:


	Is it:


	If yes, is it:

Any deck, balconies, porches


	Square footage

Are there railings on all stairs/ decks over 2 steps

Property located on more than 5 acres


	If so, how many?

Dogs/ Pets


	If yes, breed and number

Any bite history

Any household member a smoker

Pool


	If yes, is it:

Underground fuel storage tank


	Do you own a trampoline


	Fenced


	Diving board or slide

Own any recreational vehicles; if yes, list

Farming on premises


	If yes, explain

Any business or day care on premises


	If yes, explain

Applicants had a foreclosure or repossession in last 5 years