Belcher Insurance Agency

Home Insurance Quote

To obtain a free, no-obligation quote for your home or other property, fill out the form below and click on the 'Submit Form' button and we will contact you. If you prefer to give information over the phone, fill out the name and daytime phone number fields only and we'll give you a call.

If you would rather mail us this information, fill out the form and click on the 'Print This Page' button at the bottom of this page and mail to Belcher Insurance Agency, P.O. Box 667, Seagraves, TX 79359. You can also fax the completed form to us at (806) 387-2743.

Have any other questions? Please call us at (806) 387-2585.

Name:
Current Address:
City:
State:
Zip Code:
Daytime Phone:
Email Address:
DOB:
Spouse Name:
Spouse DOB:
Have you had your home or auto insured with Germania Insurance before?:
Current Insurance Company:
Expiration/Closing Date:
Bankruptcy, Foreclosure, Reposession in Last 5 Years:
Fire plug within 1,000 feet:
Responding Fire Dept:

Rating Data:

Address to Insure:
City:	State: Zip:
Acreage:
Sq. Ft. of Home (Living Area):
Year Home Was Built:
Construction of Home:
Number of Stories:
Foundation Type:
Roof Construction:
Roof Age:
Garage Attached:
Number of Bedrooms:
Number of Bathrooms:
Pool:	If Yes, diving board or slide?:
Trampoline:
Dogs:
Breeds:
Livestock? What type?:
Monitored Fire Alarm:	Monitored Burglar Alarm:

Estimated Home Value:

Optional Coverages Available:

Check All That You Wish To Include In The Quote:	Jewelry Saddles & Tack	Art Objects Farm Equipment	ATV's Farm Outbuildings

Claims:

	Any home claims in the past 5 years? If so describe... (Date, Claim Type & Amounts Paid.)

Comments:

**No insurance coverages are bound from this web site.**