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Personal Risk Analysis #7 (MICho)


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
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
Required
Homeowners Insurance
The following categories of property are limited. Do you need more than the following amounts?
Cash & Coins: $200
Optional

Securities & Stamps: $1,000
Optional

Watercraft and equipment: $1,000
Optional

Trailers not used with watercraft (camping, utility): $1,000
Optional

Jewelry & Furs: $1,000
Optional

Silverware: $2,500
Optional

Firearms: $2,000
Optional

Business property at your home: $2,500
Optional

Business property away from home: $250
Optional

Add notes here:
Optional
Motorized Vehicle Risks
Do you own any of the following motorized items:
Check any of these items you own:
Optional






List year, make, model, hp/cc, and value for any items you own:
Optional
Miscellaneous Risks
Let us know...
1. Do you own a business?
Optional

Describe:
Optional
2. Do you do daycare in your home?
Optional

Describe:
Optional
3. Do you own a cottage or second home?
Optional

Describe:
Optional
4. Do you own or rent any vacant land, a boat slip, or a trailer lot?
Optional

Describe:
Optional
5. Do you own any other land with structures on it?
Optional

Describe:
Optional
6. Do you own or rent any farm land?
Optional

Describe:
Optional
7. Do you own any rental properties?
Optional

Describe:
Optional
8. Do you rent any part of your home to others?
Optional

Describe:
Optional
9. Do you have any structures on your property not attached to the house?
Optional

Describe:
Optional
10. Do you have children living at college?
Optional

Describe:
Optional
11. Do you own any tools/equipment used in your job?
Optional

Describe:
Optional
12. Are you a member of a condo or neighborhood association?
Optional

Describe:
Optional
13. Do you have any rare or unusual property not previously listed on this questionnaire?
Optional

Describe:
Optional
14. Is your home held in a trust?
Optional

Name of trust:
Optional
Additional Protection Options
Select from below...
Water/Sump Pump Backup - Select Limit
Optional
Do You Want Identity Fraud Expense Coverage?
Optional

Do you want coverage for earthquake damage?
Optional

Do you want coverage for flood damage?
Optional

Do you want to schedule jewelry or furs?
Optional

Describe items and value:
Optional
Life Insurance
Life insurance protection
Would you like a proposal for life insurance?
Optional

Name of person to be insured:
Optional
Birth date:
Optional
Height:
Optional
Weight:
Optional
Coverage Amount:
Optional
Number of years for level premium:
Optional
When was the last time you used tobacco?
Optional
Describe any medical issues:
Optional
List any medications you currently take:
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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