Business Insurance Quote Request Form

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To get a free business insurance quote with no obligation, 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
Business Name:
Contact Name:
Mailing Address:
Street Address:
City:
State:
Zip:
Business Phone #
Fax #
Best Time To Call:	AM   PM
Email Address:

 

Current Insurance Information
Insurance Company Name
Policy Expiration Date:
Premium Amount:
Types of Coverage (Please check all that apply)
Commercial Umbrella   Professional Liability    Bond   Commercial Auto         Director/Officer Liability Group Life Commercial Liability     Disability                      Group Health Commercial Property   Completed Ops            Worker's Comp Other

 

About Your Business
Number of Full Time Employees
Number of Part Time Employees
How Long In Business
How Many Locations
Annual Sales/Revenue
Business Description/Clientele:

 

About Your Business Location
Building Construction Type:	Masonry Stucco Frame Veneer Other
Roof Material Type:	Asphalt Shingle Wooden Shingle Tile Slate Gravel Covered Tin/Metal Other
Servicing Fire Department:
Miles To Fire Department:
Distance To Fire Hydrant:	ft.

 

Coverage Desired or Required

Commercial Umbrella   Professional Liability    Bond   Commercial Auto         Director/Officer Liability Group Life Commercial Liability     Disability                      Group Health Commercial Property   Completed Ops            Worker's Comp Other

 

Additional Information

If you have additional information to add to your quote that we have not covered, please include that in this box.  Please be as specific as possible.

 

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.

Insurance Quote Forms © 2006 MainBoard, LLC Web Design - Licensee Belcher Insurance Agency, Inc.

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.