Home Owner's Insurance Quote Request Form

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To get a free home owner's 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.

 

Policy Holder Information
Name
Social Security #
Date of Birth
Occupation
Time At Current Job	Yrs.   Mos.
Spouse's Name
Spouse's Social Security #
Spouse's Date of Birth
Spouse's Occupation
Address
City
State	Zip
Daytime Phone
Nighttime Phone
Best Time To Call	AM   PM
Email Address

 

Current Home Owner's Insurance Information
Insurance Provider's Name (NOT Agent or Agency)
Policy Expiration Date
Premium Amount
Amount Insured For
Policy Type	Primary Secondary
Term	6 Months 1 Year Other (Specify Below)

 

Covered Property Information
How long have you lived at this present address?
Year your home was built?
Square Feet (exclude Garage & Basement)
Number of Claims in past 3 years
Servicing Fire Department
Miles to Fire Department Building
Distance Home is from Fire Hydrant	ft.

 

Structural Information
Type	1-Story 1 1/2-Story 2-Story 3-Story Split-Level Bi-Level Other
Construction	Frame Veneer Stucco Masonry Other
Roof	Asphalt Shingle Wood Shingle Tin / Metal Tile / Slate Other	Roof Age yrs
Foundation	Basement Crawl Space Slab Other
Garage	1-Car 2-Car 3-Car 4-Car 5-Car None	Attached Separate Built-In Basement Car Port None Other

 

Additional Features
Basement	Finished Unfinished None	Square Ft.
Bathrooms	Number of Full	Number of Half
Deck Porch Patio	Deck Square Ft.     Porch Square Ft.    Patio Square Ft.
Fireplaces	Chimneys	Hearths

 

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.