Automobile Insurance Quote Request Form

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To get a free Automobile Insurance quote with no obligation to sign, please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quoting purposes only.

 

General Information
Contact Name:
Mailing Address:
Street Address:
City:
State:
Zip:
Phone #
Best Time To Call:	AM   PM
Email Address:

 

Current Insurance Information
Insurance Company Name (Not your agent name)
Policy Expiration Date:
Premium Amount:
Term of Policy	Quarterly (3 Months) Annually Semi-Annually (6 Months)
Other Providers during the last 3 years?

 

Automobile Information
Please Include All Automobiles You or your family members own that will be covered in this policy
Auto # 1	VIN #		Year		Make		Model		Body Type
Title Holder Name		Annual Mileage		Work/School? # of Miles Driven One Way		Airbags?		Alarm?
				Yes No		Yes No		Yes No
If this vehicle is garaged at another address than listed above, please specify where.
City     State     Zip

 

Auto # 2	VIN #		Year		Make		Model		Body Type
Title Holder Name		Annual Mileage		Work/School? # of Miles Driven One Way		Airbags?		Alarm?
				Yes No		Yes No		Yes No
If this vehicle is garaged at another address than listed above, please specify where.
City     State     Zip

 

Auto # 3	VIN #		Year		Make		Model		Body Type
Title Holder Name		Annual Mileage		Work/School? # of Miles Driven One Way		Airbags?		Alarm?
				Yes No		Yes No		Yes No
If this vehicle is garaged at another address than listed above, please specify where.
City     State     Zip

 

Auto # 4	VIN #		Year		Make		Model		Body Type
Title Holder Name		Annual Mileage		Work/School? # of Miles Driven One Way		Airbags?		Alarm?
				Yes No		Yes No		Yes No
If this vehicle is garaged at another address than listed above, please specify where.
City     State     Zip

 

Liability Limit For All Automobiles
Bodily Injury $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000        Property Damage $25,000 $50,000 $100,000 $500,000	or Combined Single Limit $50,000 $100,000 $300,000 $500,000

 

Deductibles and Options
	Comprehensive Deductible	Collision Deductible	Towing	Loss of Use
Auto # 1	$100 $250 $500	$250 $500 $1000	Yes No	Yes No
Auto # 2	$100 $250 $500	$250 $500 $1000	Yes No	Yes No
Auto # 3	$100 $250 $500	$250 $500 $1000	Yes No	Yes No
Auto # 4	$100 $250 $500	$250 $500 $1000	Yes No	Yes No

 

Driver's Information Please list all drivers in your household
Driver # 1			Name					License Information
								License # State Year Licensed
Relation	Birth date				Sex	Marital Status				Courses in last 3 yrs.
Self				Male Female			Married Single		Driver's Ed. Defensive Driving

 

Driver # 2			Name					License Information
								License # State Year Licensed
Relation	Birth date				Sex	Marital Status				Courses in last 3 yrs.
				Male Female			Married Single		Driver's Ed. Defensive Driving

 

Driver # 3			Name					License Information
								License # State Year Licensed
Relation	Birth date				Sex	Marital Status				Courses in last 3 yrs.
				Male Female			Married Single		Driver's Ed. Defensive Driving

 

Driver # 4			Name					License Information
								License # State Year Licensed
Relation	Birth date				Sex	Marital Status				Courses in last 3 yrs.
				Male Female			Married Single		Driver's Ed. Defensive Driving

 

Driver # 5			Name					License Information
								License # State Year Licensed
Relation	Birth date				Sex	Marital Status				Courses in last 3 yrs.
				Male Female			Married Single		Driver's Ed. Defensive Driving

 

Driver's History List all convictions of moving traffic violations in the last 3 years
Driver Name	Date Of Offense	Type of Conviction	Fine Amount	Amount over the Posted Limit?
			$	mph
			$	mph
			$	mph
			$	mph
			$	mph

 

Suspensions - Revocations - DUI Convictions List any drivers who have been suspended, revoked or had a DUI Conviction
	License Suspended or Revoked	DUI Conviction?
Driver's Name	Suspended  Revoked Restricted for work or school   Date License Restored To Full Status Unrestricted License (Please put "Suspended" or "Revoked" if as of the date of this quote request this driver is currently suspended or revoked)	Alcohol Drugs
Driver's Name	Suspended  Revoked Restricted for work or school   Date License Restored To Full Status Unrestricted License	Alcohol Drugs
Driver's Name	Suspended  Revoked Restricted for work or school   Date License Restored To Full Status Unrestricted License	Alcohol Drugs
Driver's Name	Suspended  Revoked Restricted for work or school   Date License Restored To Full Status Unrestricted License	Alcohol Drugs
Driver's Name	Suspended  Revoked Restricted for work or school   Date License Restored To Full Status Unrestricted License	Alcohol Drugs

 

Accidents In Past 5 Years List any drivers involved in an accident in the past 5 years regardless of fault
Driver	Date	Description	Total Costs	Fines	Injuries	At Fault
					Yes No	Yes No
					Yes No	Yes No
					Yes No	Yes No
					Yes No	Yes No
					Yes No	Yes No

 

Additional Information Please describe any pertinent information that we did not ask on the forms above

 

Permission To Obtain Consumer Reports (Required To Quote)
To provide you with an accurate quote, we have asked you a series of questions, some of which we must confirm through consumer reports. These reports may include credit, motor vehicle and loss information reports from the respective consumer reporting departments/agencies. This information will be available to our companies with whom we will obtain your quote.
Do You Grant Permission to B.I.A., Inc. To Obtain These Reports?	Yes          No

 

Virginia Fraud Statement
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
I Have Read The Virginia Fraud Statement and Verify that all information is accurate to the Best of my Knowledge and do consent for B.I.A., Inc. to process my Free Quote Request.	I AGREE I DO NOT AGREE

 

 

C.C. Belcher Insurance Agency 503 Main Street P.O. Box C (Mail Correspondence) Haysi, VA 24256 Phone: (276) 865-5144 Trucker's Only: 1-877-411-2421 Fax: (276) 865-5255 Email: matt@belcherinsurance.com

Website Content © Copyright 2006 - C. C. Belcher Insurance Agency, Inc.

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Notice: This website provides a simplified description of coverage only and is not a statement of contract. Coverage may not apply in all states. For complete details of coverage,  conditions, limits and losses not covered, be sure to read the policy, including all endorsements.