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To submit a COMMERCIAL QUOTE, please complete the form below.
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*Name Insured: 
*Contact Name: 
*Contact Phone:  ( )    Ext. 
Email: 
Thorough Description of Operations: 
Number of Locations:   Number of  Employees:  
Coverage Required: 
Annual Sales: 
Annual Payroll: 
Years in Business:   Years Exeperience:  
  Currently Insured?
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Names of Carrier: 
Date of Coverage Needed: 

The Briceland Agency, Inc.   6633 Main Street, Buffalo New York 14221-5996
Toll Free: 1-800-724-7145   Telephone: (716) 631-8800   Facsmile: (716) 631-2848

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