Centennial Insurance Agency - Your Insurance Resource Center

"Your Insurance Resource Center"

(631) 207-5400

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(631) 207-5400

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General Information

Full Name:

Day Telephone:

Street Address:

Eve Telephone:

City, State & Zip:

Fax:

E-Mail Address:

Your occupation:

Best Time To Reach You:

Date of Birth:

Current Insurance Information

Insurance Company Name:
(NOT Insurance Agency/Broker)

Policy Exp. Date:

Contents Insured for:

Current Ded:

Premium Amt:

Policy Term:

Condominium Information

Will you or do you live on this property:	Yes No
How much coverage do you want on your personal property:	$
How much personal liability:	$100,000 $300,000 $500,000 $1,000,000
Deductible:	$500 $1,000 $2,500
Number of Units:
Number of Stories:
Is there a 24-hour door man:	Yes No
Are there elevators:	Yes No
Year Built:	(yyyy)
Approximate Square Feet:
Have you reported any claims or losses to your insurance company within the last 5 years	Yes No
Type of Construction:	Brick Wood frame Cinder block Other
Roof Type:	Composite shingle Tile Wood shingle Other
Roof Age:	Years (if unknown, please indicate)
Burglar Alarm:	Yes No
Heating System:	Forced air Electric Boiler Oil Propane
Number of gas or wood fireplaces or stoves:
What floor do you live on:
Number of bathrooms:

Additional Information

Any business conducted in home: (if Yes, please describe)

Yes No

List values of any jewelry, furs, or specialty items:

List pets & breeds:

Additional Comments

Please give any additional comments or questions

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We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.
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Centennial Insurance Agency, Inc
"Your Insurance Resource Center"
Give us a Call Today!
(631) 207-5400