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Auto Insurance Quote Form


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.

Personal Information
First Name
Required
Last Name
Required
Street
Required
City
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State
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ZIP / Postal Code
Required
Prior address if you moved in the last 6 months
Optional
Primary Phone Number
Required
Alternate Phone Number
Optional
E-Mail Address
Required
Do you rent or own your residence?
Required
Do you currently have insurance?
Optional
If no, when did you last have insurance?
Optional
/ /
If no current policy, please tell us why:
Optional
Current Policy End Date
Optional
/ /
Current Auto Insurance Company
Required
Current Premium
Optional
Bodily Injury Liability Limits on your CURRENT policy
Required
List all claims in last 3 years
Optional
Select group discount
Required
List any other groups you belong to
Optional
How did you hear of our agency?
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If by referral, who referred you?
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Why are you shopping?
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Tell us how we can best meet your needs!
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Add notes here:
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Select Your Coverages
Bodily Injury Liability
Required
Property Damage Liability
Required
Personal Injury Protection - Medical
Required
Personal Injury Protection - Work Loss
Required
Uninsured Motorist Bodily Injury
Required
Under-Insured Motorist - Bodily Injury
Required
Property Protection Insurance
Optional
Mini-Tort Coverage
Required
Vehicle Information
Vehicle One
Year
Optional
Make
Required
Model
Required
VIN #
Optional
Safety Devices
Optional




Comprehensive Deductible
Required
Type Of Collision Coverage
Required
Collision Deductible
Optional
Towing Limit
Optional
Rental Reimbursement Limit
Optional
Vehicle Two
Year
Optional
Make
Optional
Model
Optional
VIN #
Optional
Safety Devices
Optional




Comprehensive Deductible
Optional
Type Of Collision Coverage
Optional
Collision Deductible
Optional
Towing Limit
Optional
Rental Reimbursement Limit
Optional
Vehicle Three
Year
Optional
Make
Optional
Model
Optional
VIN #
Optional
Safety Devices
Optional




Comprehensive Deductible
Optional
Type Of Collision Coverage
Optional
Collision Deductible
Optional
Towing Limit
Optional
Rental Reimbursement Limit
Optional
Vehicle Four
Year
Optional
Make
Optional
Model
Optional
VIN #
Optional
Safety Devices
Optional




Comprehensive Deductible
Optional
Type Of Collision Coverage
Optional
Collision Deductible
Optional
Towing Limit
Optional
Rental Reimbursement Limit
Required
Driver Information
Number of household members:
Required
How many licensed drivers in your household?
Required
Driver One
Name of Driver (First, Last)
Required
Marital Status
Required
Gender
Optional
Date of Birth
Required
/ /
Driver's License Number
Optional
Education Level
Required
Occupation
Optional
Which vehicle does this driver use the most?
Required
How is vehicle used?
Optional
List all violations, accidents, and claims in last 3 years
Optional
Driver Two
Name of Driver (First, Last)
Optional
Marital Status
Required
Gender
Optional
Date of Birth
Required
/ /
Driver's License Number
Optional
Education Level
Optional
Occupation
Optional
Which vehicle does this driver use most?
Optional
How is vehicle used?
Optional
List all violations, accidents, and claims in last 3 years
Optional
Driver Three
Name of Driver (First, Last)
Optional
Marital Status
Optional
Gender
Optional
Date of Birth
Required
/ /
Driver's License Number
Optional
Education Level
Optional
Occupation
Optional
Which vehicle does this driver use most?
Optional
How is vehicle used?
Optional
List all violations, accidents, and claims in last 3 years
Optional
Driver Four
Name of Driver (First, Last)
Optional
Marital Status
Optional
Gender
Optional
Date of Birth
Optional
/ /
Driver's License Number
Optional
Education Level
Optional
Occupation
Optional
Which vehicle does this driver use most?
Optional
How is vehicle used?
Optional
List all violations, accidents, and claims in last 3 years
Optional
Do you rent or own your home?
Optional
Submission Validation
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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.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Boer Insurance Group | 2535 Five Mile Road NE, Grand Rapids, MI 49525 | Ph: 616-363-7766 | Fx: 616-363-6626
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