Life - Health - Accident Insurance Quote Request Form

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To get a free Life - Health - Accident Insurance quote, 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
Address
City
State
Zip
Home Phone
Work Phone
Best Time To Call	AM    PM
Email Address

 

Information About Policy Holder & Family Members
	Policy Holder	Spouse	Child 1	Child 2	Child 3
Name	Self
Date of Birth
Sex	Male Female	Male Female	Male Female	Male Female	Male Female
Marital Status	Married Separated Divorced	Married Separated Divorced	Married Separated Divorced	Married Separated Divorced	Married Separated Divorced
Occupation
Height	ft  in	ft  in	ft  in	ft  in	ft  in
Weight	lbs.	lbs.	lbs.	lbs.	lbs.
Pre-Existing Health Conditions	Heart  Cancer Diabetes High BP	Heart  Cancer Diabetes High BP	Heart  Cancer Diabetes High BP	Heart  Cancer Diabetes High BP	Heart  Cancer Diabetes High BP
Tobacco User	Y N	Y N	Y N	Y N	Y N

 

History of Insured or To Be Insured Please List Any and All Present or Past Histories
Self	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes     No     (If Yes, describe in detail below)
Spouse	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes     No     (If Yes, describe in detail below)
Child 1	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes     No     (If Yes, describe in detail below)
Child 2	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes     No     (If Yes, describe in detail below)
Child 3	Is person to be insured currently on any prescription medications for ongoing health conditions? Yes     No     (If Yes, describe in detail below)

 

Life Insurance Coverage
	Policy Holder	Spouse	Child 1	Child 2	Child 3
Amount of Coverage	$	$	$	$	$
Type of Coverage	Term Whole Universal	Term Whole Universal	Term Whole Universal	Term Whole Universal	Term Whole Universal
Disability Income	Yes No	Yes No	N/A	N/A	N/A
Long Term Care	Yes No	Yes No	N/A	N/A	N/A

 

Accident Policy Coverage
Policy Holder	Spouse	Child 1	Child 2	Child 3
Yes No	Yes No	Yes No	Yes No	Yes No

 

Health Insurance Coverage
	Policy Holder	Spouse	Child 1	Child 2	Child 3
Add Health Coverage?	Yes No	Yes No	Yes No	Yes No	Yes No
Please select the desired types of coverage below
High Deductible No-Deductible Co-Pay Metal Health Maternity Chiropractic			Dental Vision Preventative Care Acupuncture Other (Please describe below)
Please list any coverage type not listed above you would like to have quoted if it is available.

 

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

 

 

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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

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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.