Supplemental Applications
Forms
Looking for a form? All of our forms are available for download and can be filled out on your device.
Basic
Authorization for ACH Direct Debits
Credit Card Payment Authorization
Credit/Debit Card Payment by Phone
Email Delivery Approval Form for OfficeScope
Midrox Restaurant Questionnaire
Midrox Landlord Package Application
Midrox Supplemental Residence Application
Optional Basic Economic Loss (OBEL) Coverage
Supplementary Uninsured/Underinsured Motorists Insurance
Acknowledgement of Requirement for Photo Inspection
Safeco Supplemental Auto Quote Sheet
Part C Affidavit by Producing Broker
Lancer
Commercial Automobile Application
Utica First
Antiques and Collectibles Supplement
Automobile Service or Repair Station Supplemental
Convenience Store Supplemental
Food Service/Restaurant and Tavern Application
Mandatory Artisan Contractors Supplemental Application
Exclusion of Injury to Employees, Contractors, and Employees of Contractors
Exclusion – Commercial Spray Painting
Roofing Operation Specification Exclusion Endorsement
Buy Back Exclusion Endorsement – Snow Removal Operations
Exclusion – Snow Removal Operations
Notice of Terrorism Insurance Coverage – CT/PA/OH
Notice of Terrorism Insurance Coverage – NY/NJ
Exclusion of Injury to Employees, Contractors, and Employees of Contractors – NY
New Business
Trish – Underwriter
Direct: 347-821-3215
Toll-Free: 800-403-3738 x120
trishc @chenangobrokers.com
Theresa – Underwriter
Direct: 347-269-1574
Toll-Free: 800-403-3738 x115
[email protected]
Miranda – Underwriter
Direct: 347-821-3221
Toll-Free: 800-403-3738 x103
[email protected]
Dulcie – Underwriter
Direct: 347-821-3225
Toll-Free: 800-403-3738 x104
[email protected]obrokers.com
Audrey – Underwriter
Direct: 347-821-3228
Toll-Free: 800-403-3738 x105
[email protected]
Customer Service
Alle-Team Leader/Certificates
Direct: 347-821-3216
Toll-Free: 800-403-3738 x107
[email protected]
Kaitlin - Customer Service
Direct: 347-821-3244
Toll-Free: 800-403-3738 x113
[email protected]
Marketing
Jamie Deapo-Agency Relations Manager
Direct: 347-269-1645
Toll-Free: 800-403-3738 x116
[email protected]
Office Manager
Robin Bartholomew
Direct: 347-821-3249
Toll-Free: 800-403-3738 x101
[email protected]
