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
Part C – Affidavit by Producing Broker
Acknowledgement of Requirement for Photo Inspection
Safeco Supplemental Auto Quote Sheet
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
theresab@chenangobrokers.com
Miranda – Underwriter
Direct: 347-821-3221
Toll-Free: 800-403-3738 x103
mirandag@chenangobrokers.com
Dulcie – Underwriter
Direct: 347-821-3225
Toll-Free: 800-403-3738 x104
dulcies@chenangobrokers.com
Audrey – Underwriter
Direct: 347-821-3228
Toll-Free: 800-403-3738 x105
audreyo@chenangobrokers.com
Customer Service
Alle-Team Leader/Certificates
Direct: 347-821-3216
Toll-Free: 800-403-3738 x107
allec@chenangobrokers.com
Kaitlin - Customer Service
Direct: 347-821-3244
Toll-Free: 800-403-3738 x113
kaitlinm@chenangobrokers.com
Marketing
Jamie Deapo-Agency Relations Manager
Direct: 347-269-1645
Toll-Free: 800-403-3738 x116
jamied@chenangobrokers.com
Office Manager
Robin Bartholomew
Direct: 347-821-3249
Toll-Free: 800-403-3738 x101
robinb@chenangobrokers.com
