Personal Quote Form

If you're looking for a quick quote you've come to the right place! Simply fill out the form below and we'll be in touch. If you'd like to supply more information, expand any of the sections below and we'll get to work on a quote that serves your needs and saves you money.

Questions? Please contact us. If you would like a business insurance quote, please click here.

   
Quick Quote
Line(s) of insurance for which I would like a quote:

For a more accurate quote, please be sure to click on to expand and complete the corresponding sections below:

Automobile Insurance

(includes antiques, motorcycles, private passenger vehicles, motorhomes, and travel trailers)

Do you currently have automobile insurance? Yes No

Using the tables below, please provide details on the driver(s) and vehicle(s) being insured (by providing this information you are authorizing Ellis Insurance to obtain additional driver and vehicle information from your state’s Registry of Motor Vehicles). If you have more than four drivers and/or vehicles, please contact us at 800-824-4455.


Vehicle 1 Vehicle 2 Vechicle 3 Vehicle 4
Vehicle Type
Vehicle Type
Vehicle Type
Vehicle Type
Year/Make/Model
Year/Make/Model Year/Make/Model Year/Make/Model
Plate Number or VIN
Plate Number or VIN Plate Number or VIN Plate Number or VIN
Registration State:
Registration State: Registration State: Registration State:
Alarm System
Alarm System Alarm System Alarm System
Physical Damage Coverage* Physical Damage Coverage* Physical Damage Coverage* Physical Damage Coverage*

 

Additional vehicle information

For antique vehicles, please provide estimated/appraised value. For motorcycles, please provide engine displacement (cc’s). Please note the value of any custom parts or equipment.

Please select a deductible for physical damage to your vehicle (includes collision, theft, vandalism, etc).

Protection Level Optional Bodily Injury* UM and UIM Coverage* Property Damage*
$50,000/$100,000 $50,000/$100,000 $100,000
$100,000/$300,000 $100,000/$300,000 $100,000
$250,000/$500,000 $250,000/$500,000 $200,000

For liability limits over $250,000/$500,000 we recommend a personal umbrella, offered as an endorsement to your homeowners policy.

Please check any additional services you would like included in your quote:

Have you or any listed drivers had any automobile losses in the last 3 years: Yes No

If yes, please describe (include name of driver, date of loss and total amount paid):

Domestic Employees
Job Description Employment Location # of employees
(please use ½ for part-time employees)

* please provide total annual payroll for physical assistant(s):$

Please select an Employer’s Liability coverage limit:

Flood

Please describe the location to be insured

Homeowner's Insurance
RESIDENCE #1 (Primary)    
Do you currently have home insurance? yes no
With whom?  
When does it expire?  
Physical address of this property:
street
 
city
   
 
postal code
Is this your primary residence?
(please note that only one residence can be primary)		 yes no
Is this location a private residence, condominium/townhouse, apartment, or investment property?
 yes no
If this is a PRIVATE RESIDENCE or INVESTMENT PROPERTY  
How much do you currently have the structure insured for (if this is a new purchase then please enter 0)
Number of families
Approximate square footage   (excluding basement)
If this is a CONDOMINIUM or APARTMENT please provide your personal property limit. This limit reflects the value of the contents of your home
Please select building construction material
Approximate year of construction
Please describe any renovations (including the year) completed within the past 20 years
Any losses at this location in the last 5 years yes no
If yes, please describe (include brief description, date of loss, and total amount paid)
Safety Features
(please check all that apply)		 Smoke Detectors
  Deal Bolt Locks
  Fire Extinguisher
  Non-Smoker
  Central Station Burglar Alarm
  Central Station Fire Alarm
  Police Station Direct Alarm
  Fire Department Direct Alarm
  Automatic Sprinklers
Do you (or your tenants) have any pets? yes no
If yes, please describe (including breed)
What is your preferred deductible?
What is your preferred liability limit?
Umbrella liability limit

Residence 2 - Please contact us at 800-824-4455 if you have more than two residences.

     
Do you currently have home insurance?   yes no
With whom?  
When does it expire?  
Physical address of this property:
street
 
city
   
 
postal code
Is this your primary residence?
(please note that only one residence can be primary)		 yes no
Is this location a private residence, condominium/townhouse, apartment, or investment property?
 yes no
If this is a PRIVATE RESIDENCE or INVESTMENT PROPERTY  
How much do you currently have the structure insured for (if this is a new purchase then please enter 0)
Number of families
Approximate square footage   (excluding basement)
If this is a CONDOMINIUM or APARTMENT please provide your personal property limit. This limit reflects the value of the contents of your home
Please select building construction material
Approximate year of construction
Please describe any renovations (including the year) completed within the past 20 years
Any losses at this location in the last 5 years yes no
If yes, please describe (include brief description, date of loss, and total amount paid)
Safety Features
(please check all that apply)		 Smoke Detectors
  Deal Bolt Locks
  Fire Extinguisher
  Non-Smoker
  Central Station Burglar Alarm
  Central Station Fire Alarm
  Police Station Direct Alarm
  Fire Department Direct Alarm
  Automatic Sprinklers
Do you (or your tenants) have any pets? yes no
If yes, please describe (including breed)
What is your preferred deductible?
What is your preferred liability limit?
Umbrella liability limit

Recreational and Off-road Vehicles (including ATVs, dirt bikes, and snowmobiles)
Do you currently have recreational vehicle insurance? yes no
With whom?
When does it expire?

Using the tables below, please provide details on the driver(s) and recreational vehicle(s) being insured (by providing this information you are authorizing Ellis Insurance to obtain additional driver information from your state’s Registry of Motor Vehicles). If you have more than two drivers and/or recreational vehicles, please contact us at 800-824-4455.

Driver Name Date of Birth License Number License State
Vehicle type Year, make and model Engine displacement (CCs) Estimated value Town and Zip code for garaging location Is the vehicle kept in a fully enclosed, locking structure?* Physical damage coverage (deductible for Collision and Comprehensive)
             

LIABILITY COVERAGE Please choose your liability coverage:

Protection Level Bodily Injury Property Damage
$50,000/$100,000 $100,000
$100,000/$300,000 $100,000
$250,000/$500,000 $250,000

Have you or any listed drivers had any accidents or losses in the last 5 years yes no

If yes, please describe (include name of driver, date of loss and total amount paid)

Watercraft Insurance
Do you currently have watercraft insurance? yes no
With whom?
When does it expire?

Using the tables below, please provide details on the operator(s) and watercraft(s) being insured (by providing this information you are authorizing Ellis Insurance to obtain information from your state’s Registry of Motor Vehicles). If you have more than two operators and/or watercraft, please contact us at 800-824-4455.

Operator Name Date of Birth Social Security or Driver's License # License State Years of boat ownership

Watercraft 1 Watercraft 2
Hull Type
 Hull Type
Year, make and model
Year, make and model
Registration # and/or hull id #
 Registration # and/or hull id #
Length
 Length
Power Type
 Power Type
Horsepower
 Horsepower
Max speed
 Max speed
Est value
 Est value
Physical damage coverage
(deductible for Collision and Comprehensive)
 Physical damage coverage
(deductible for Collision and Comprehensive)
Town and zip code for primary location of watercraft*
 Town and zip code for primary location of watercraft*

*If no location is provided, the quote will assume the watercraft is stored at the address provided in “General Information.”

LIABILITY COVERAGE Please choose your liability coverage:

Protection Level Bodily Injury Property Damage
$50,000/$100,000 $100,000
$100,000/$300,000 $100,000
$250,000/$500,000 $250,000

Optional coverages

Please select from the following:

Personal Effects Towing Boat Trailer (property coverage) Uninsured boater Watersports liability

Have you or any listed drivers had any accidents or losses in the last 5 years: yes no

If yes, please describe (include name of driver, date of loss and total amount paid):

Wine Insurance
Is your collection currently insured? yes no
With whom?
When does it expire?
Is your entire collection stored on your premises? yes no
If NO please describe any additional locations
Is your collection stored in an environmentally controlled area? yes no
Has your collection been appraised by a certified wine appraiser? yes no
Do you have a security system? yes no
Insurance coverage can be provided on a BLANKET and an ITEMIZED basis. We limit the per bottle limit on blanket coverage to $50,000, although we recommend itemizing bottles with values greater than $10,000. Blanket and Itemized coverage can be included on the same policy.
Blanket Limit requested?
TOTAL Itemized Limit requested?

* Please note that our wine coverage includes (at no additional charge):

  • $0 deductible
  • New purchase protection (for itemized collections only) – automatically provides up to 100% of the itemized limit for new purchases for up to 90 days
  • Worldwide coverage – your wine is protected worldwide, and while in transit

Valuable Possessions

Homeowner’s insurance policies provide limited coverage for certain types of property. To ensure that all your possession are quoted appropriately, please list them below. If insured in this fashion, items listed will enjoy increased limits, worldwide coverage, and will not be subject to deductibles in the event of a loss.

Please provide information on the property to be insured:

  Coverage Amount General Description
Fine arts
Furs
Jewelry
Musical instruments
Other

Submitting an insurance quotation request to Ellis Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Ellis Insurance Agency to confirm binding or altering coverage.