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.
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Get A Quote- Antqiue and Classic

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oneida lake chamber

Oneida Lake/ Ft. Brewerton Chamber of Commerce

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Camden Chamber of Commerce
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Cazenovia Chamber of Commerce

Please fill out the following form to the best of you knowledge and we will quote your policy as soon as possible. If we need additional information we will contact you.

The following questions are used to help determine the proper company and rate to assign to your risk. Answering the questions will only help your rate and will not hurt it. You do not have to answer anything you do not want to. We do not give out or sell any information provided. We will run motor vehicle reports and accident reports to verify all information provided. To Qualify vehicle must be stored in a locked garage.

Name

Mailing Address

Garaging Address

Do you own your home, rent or live with someone else

Do you currently have antique insurance

What company

* To qualify, you must provide a DEC page of regular auto policy *

Has your insurance (regular or antique) ever been canceled, declined or non-renewed in the last 5 years? Why

Licensed Drivers

primary driver

Name on license

Drivers license number

Male

Female

Social Security Number

Single

Married

License state

Date of birth

Occupation

Highest level of education

Explain all ticket and accidents (5 years)

Name on license

Drivers license number

Male

Female

Social Security Number

License state

Single

Married

Date of birth

Occupation

Highest level of education

Relationship to applicant

Other licensed household members

Full name

DOB

Vehicles

Year

Make

Model

License number

VIN number

Vehicle value

Primary driver

Loan on vehicle

Physical Damage

Check all safety feature that apply:

Air Bags

Anti-Lock Brakes

Anti-theft

Year

Make

Daytime running lights

Model

VIN number

Vehicle value

Primary driver

Loan on vehicle

Physical Damage

Check all safety feature that apply:

Air Bags

Coverages

Liability

Anti-Lock Brakes

Anti-theft

Medical

Additional PIP

Daytime running lights

OBEL

Uninsured/ Underinsured

Comprehensive Deductible

Collison Deductible

Rental

Towing

Other

Contact Info.

Phone

Preferred method of contact

US Mail