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Insurance Cancellation Questionnaire


We're sorry to see you go!  Please help us understand where we failed to meet your expectations so we can improve our service and potentially be of service to you in the future.  Please fill out the form below with as much information as you feel comfortable providing.  We truly appreciate your willingness to help us improve.

Personal Information
First Name
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Last Name
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
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Please Let Us Know...
Reason(s) for cancelling insurance (check all that apply):
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Please elaborate on reasons noted above:
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What insurance company did you switch to?
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What is your new premium?
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Comments or Notes:
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Rate Our Service...
Who did you work with most at our agency?
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Hold down the Ctrl Key to make multiple selections.
Rate your main contact's helpfulness
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Any issues with our staff?
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How can we improve our service?
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Can we contact you in the future?
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Thank You! We appreciate your feedback.
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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