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Personal Insurance Analysis


Please complete this form as thoroughly as possible to help us fully analyze your insurance needs.  The goal of everything we do in our agency, this form included, is to ensure you have the financial security needed now and in the future.  You'll find brief explanatory notes to aid in understanding the coverage being addressed when you hover over the answer field of certain questions. 

Thanks for taking the time to help us manage your insurance as proficiently as possible.  If you have any questions about this form, please don’t hesitate to call our office.  We’re happy to help with this or anything else you need.


Personal Information
First Name
Required
Last Name
Required
Primary Phone Number
Required
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 your home: $250
Optional

Carpets (except wall to wall), tapestries, wall hangings: $5,000 per article/$10,000 total
Optional

Trading cards: $1,000
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

Describe:
Optional
Select from below...
Sump Pump/Drain Water 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

Scheduling jewelry on your Homeowner's Policy provides the benefits of no deductible, broadened coverage to include losing a scheduled item, and claim settlement up to the scheduled limit for each item.
Describe items and value:
Optional
Do any of your vehicles have the following items?
CDs or tape cassettes?
Optional

Permanently installed stereo equipment worth over $1,000?
Optional

Stereo equipment that is not permanently installed?
Optional

Snowplows, pickup toppers, or other equipment not part of the original manufacture?
Optional

Add notes here
Optional
General Questions
Are all the vehicles insured on your policy titled or leased to you and/or your spouse?
Optional

Are any of your vehicles used to deliver property, such as pizzas, food, newspapers, etc.?
Optional

Do you use your vehicle in a ride service, such as Uber, Lyft, Sidecar, or others?
Optional

Are you provided with a company car?
Optional

If yes, you may be able to add "Extended Non-Owned" coverage to your personal auto policy. This will give you liability coverage for use of the company car over and above the coverage provided by your employer's auto policy. This can be important if a co-employee is injured while riding with you in the company car and sues you (lawsuits between co-employees are normally excluded from a business auto policy), or if you have a lawsuit that exceeds the amount of coverage on your employer's policy (or it lapsed), or your employer's auto insurance company claims you were using the car outside the scope of permission granted by your employer and denies coverage.
Add Extended Non-Owned coverage?
Optional

Personal Injury Protection
Personal Injury Protection (PIP) is required for all vehicles registered in Michigan. It pays your medical bills resulting from an auto accident and loss of wages up to 85% of your gross income for up to three years. The current maximum payable for wage loss is $5,452/month ($65,424/year).
Extend Wage Loss benefit beyond 3 years?
Optional

Increase Wage Loss above $5,452 per month?
Optional

Does your medical insurance EXCLUDE injuries from auto accidents?
Optional

Recommended Minimum Auto Insurance Limits
Bodily Injury Liability: $500,000 per person/$500,000 per accident. Increase your policy to these limits?
Optional

Property Damage Liability: $500,000 per accident: Increase your policy to these limits?
Optional

Uninsured Motorist: $500,000 per person/$500,000 per accident: Increase your policy to these limits?
Optional

Under-Insured Motorist: $500,000 per person/$500,000 per accident: Increase your policy to these limits?
Optional

Comments or Notes:
Optional
Life Insurance
Would you like a proposal for life insurance?
Optional

Name of person to be insured:
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
Umbrella Liability
An Umbrella Liability Policy provides liability protection in excess of your underlying auto, home, and certain other liability policies. It also provides worldwide auto liability coverage.
Are You Interested In A Premium Estimate for Umbrella Liability Insurance?
Optional


Choose The Policy Limit To Quote
Optional
Number of autos you own
Optional
Number of vehicles provided by your employer for your personal use
Optional
Number of drivers under 25 years old
Optional
Number of homes you own
Optional
Number of rental dwellings you own
Optional
Number of Recreational vehicles you own
Optional
Number of Boats you own
Optional
Submission Validation
Required
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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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