"Your Insurance Resource Center"
 





(631) 207-5400



SAVE AN ADDITIONAL 10% ON YOUR
CAR INSURANCE!

COMPLETE OUR ONLINE DEFENSIVE DRIVING COURSE NOW!

Click on the banner to enroll in our NY state-certified program.


IMPROV Comedy Traffic School


View Sharon Hamilton's profile on LinkedIn


Contact Us

CALL US
(631) 207-5400

FAX US
(631) 207-5401

E-MAIL US
info@centennialagency.com




NOT A CUSTOMER YET?

Click here to find out why you should be!



Customer
Testimonials


Testimonial
Click on the pictue
to visit this valued
customer's website
or click here to see
our next testimonial.



 
Umbrella Insurance Quote

Complete the short form below and we will get back to you with your free quote


General Information
Full Name:  
 
Street Address:  
 
City, State & Zip:  
 
E-Mail Address:  
 
Day Telephone:  
Eve Telephone:  
Best Time To Reach You:
Fax:  
Your occupation:  
Date of Birth:  

Underwriting Information:
Are any aircraft owned, leased, chartered or furnished for regular use?YesNo
Do any drivers have mental or physical impairments?YesNo
Are any premises, vehicles, watercraft, aircraft used for business?YesNo
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?YesNo
Do you engage in any type of farming operation? YesNo
Do you hold any non-remunerative positions?YesNo
Do you employ any residence employees?YesNo
Any non-owned property exceeding $1,000 in value in your care, custody or control?YesNo
Any non-owned business or professional activities included in the primary policies?YesNo
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?YesNo
Was any coverage declined, cancelled or non-renewed within the past 5 years?YesNo
Any motorcycles, mopeds or all terrain vehicles owned? YesNo
Any other business activities conducted from your residence or premises?YesNo
Please explain any YES answers from above
Are there drivers under 25 yrs of age?
If yes state how many:
What is the number of autos you own?
What is the number of recreational vehicles you own?
What is the number of single family dwellings you own?
What is the number of multi-unit buildings you own?
What is the number of vacant property (land) you own?
What is the number of motorcycles you own?
Where there any losses or claims in the last 5 years?YesNo
If yes, what is the date, amount paid and description of each loss or claim?
What is the liability limit requested?

Comments or Questions:

No coverage of any kind is bound or implied by submitting information via this online form

  • 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.
  • By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

 

YES! I Agree

PIA Logo Centennial Insurance Agency, Inc
"Your Insurance Resource Center"

Give us a Call Today!
(631) 207-5400
Medford Chamber of Commerce