COVID-19 Business Income Loss

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Business Information

Business Name *

First Name *

Last Name *

Street *

City *

State

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Loss Overview

Type of Loss *

Date and Time of Incident *

Describe the Incident *

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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Valley Agency Company
(717) 264-4311
797 Fifth Avenue - Chambersburg, PA 17201