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Test Custom Fields


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.

Additional coverage options
Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
# of 3/4 Baths
Optional
# of Full Baths
Optional
# of Half Baths
Optional
# of Kitchens
Optional
1 = Poor, 5 = Outstanding
1. Do you own a business?
Optional

10. Do you have children living at college?
Optional

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

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

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

14. Is your home held in a trust?
Optional

1st Porch Type
Optional
2. Do you do daycare in your home?
Optional

2nd Garage # of stalls
Optional
2nd Garage Type
Optional
2nd Porch Type
Optional
3. Do you own a cottage or second home?
Optional

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

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

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

7. Do you own any rental properties?
Optional

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

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

Ability to access our staff
Optional
Ability to address your needs promptly
Optional
Accept these limits?
Acrylic/Nylon Carpet
Required
Acrylic/Nylon Carpet %
Optional
Add Any Notes Here:
Optional
Add Extended Non-Owned coverage?
Optional

Add notes here:
Optional
Additional Owner Name
Optional
Additional Protection Options
Address of Dwelling to be Insured
Optional
Age of roof
Optional
Aluminum
Required
Aluminum %
Optional
Amount of insurance to quote:
Optional
Annual Payroll For This Work:
Optional
Any business conducted on premises?
Optional
Any claims in the last 5 years?
Optional
Any issues with our staff?
Optional
Any problems with current insurance we can help solve?
Optional
Any Smokers in Household?
Required

Any smokers in the household?
Required

Approximate market value of home:
Optional
Are all the vehicles insured on your policy titled or leased to you and/or your spouse?
Optional

Are any of the above items used on property other than your own?
Required

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

Are there any smokers living in your home?
Optional

Are you a member of a condominium or neighborhood association with bylaws?
Required

Are you interested in a premium estimate for an Umbrella Liability policy (covers $1,000,000 above your auto and home liability for large lawsuits against you)?
Required

Are You Interested In A Premium Estimate for Umbrella Liability Insurance?
Optional


Are you interested in a quote for Identity Theft insurance?
Required

Are you provided with a company car?
Optional

Attention
Optional
Attitude
Optional
Auto Insurance
Auto Insurance
Optional
Below are our recommended MINIMUM limits for several coverages. Indicate whether or not you accept these limits for your policy. Higher limits are also available.
Availability
Optional
BASEMENT STYLE
Optional
Bid Amount ($)
Optional
Bid Bond Percentage
Optional
Bid Date
Optional
/ /
Birth date:
Optional
Block
Required
Block %
Optional
Block %
Optional
Boats and equipment worth over $1,000?
Required

Bodily Injury Liability: $500,000 per person/$500,000 per accident Pays defense costs and judgement against you for injuries or death you've caused in a car accident.
Bodily Injury Liability
Required
Bodily Injury Liability Limits on your CURRENT policy
Required
Bodily Injury Liability: $500,000
Optional

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

Bond Information
Bond Type
Optional

Bookcase Walls
Optional
BREEZEWAY
Optional
Brick
Required
Brick %
Optional
Business hours (8:30am to 5:00pm)
Optional
Business property at your home: $10,000
Optional

Business property at your home: $2,500
Optional

Business property at your home: $5,000
Optional

Business property at your home: $5,000
Optional

Business property at your home: $5,000
Optional

Business property away from home: $1,000
Optional

Business property away from home: $250
Optional

Business property away from your home: $250
Optional

Business property away from your home: $250
Optional

Business property away from your home: $250
Optional

Business property away from your home: $5,000
Optional

Business Website Address
Optional
Camping, Utility, or other trailers worth over $1,000?
Required

Can we contact you in the future?
Optional

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

Cash & Coins: $1,000
Optional

Cash & Coins: $1,000,000
Optional

Cash & Coins: $1,500
Optional

Cash & Coins: $200
Optional

Cash & Coins: $200
Optional

Cash & Coins: $200
Optional

Cash & Coins: $200
Optional

Cash & Coins: $750
Optional

Cash & Coins: $750
Optional

Cash & Coins: $750
Optional

Cash or coin collections worth over $200?
Required

CB radios, two-way radios, installed cell phones?
Optional

CCs or horsepower
Optional
CDs or tape cassettes?
Optional

CENTRAL AIR
Optional

Central Air Conditioning?
Optional
Ceramic Tile
Required
Ceramic Tile %
Optional
Ceramic Tile %
Optional
Check all of the following items you have:
Optional









Check all of the items you have:
Optional








Check any medical conditions you've had:
Optional




Check any of the conditions you've had:
Optional


Hold down the Ctrl Key to make multiple selections.
Check any of the following items you have:
Optional
Check any of the following motorized vehicles you own
Optional




Check any of these items you own:
Optional






Check Coverages You Need:
Optional





Check if you have any of the following:
Optional


Hold down the Ctrl Key to make multiple selections.
Choose The Policy Limit To Quote
Optional
City & State of Birth
Optional
Clerical Employees Annual Payroll
Optional
Collision Deductible
Optional
Collision Deductible
Optional
Collision Deductible
Optional
Comments about Client Service Manager
Optional
Comments about our agency services
Optional
Comments or Notes:
Optional
Company Owner(s)
Comprehensive Deductible
Optional
Comprehensive Deductible
Optional
Comprehensive Deductible
Optional
Comprehensive Deductible
Required
Concrete
Required
Condo Information
Construction Type
Required
Coverage amount needed
Optional
Coverage Amount:
Optional
The descriptions of coverage shown above are in general terms and do not alter the coverage provided by the policy. Please refer to your policy for specific details.
Coverage Information
Current Auto Insurance Company
Required
Current Insurance Company
Optional
Current Policy Expiration Date
Optional
Current Premium
Optional
Daily Limit
Optional

Date Contract Entered Into
Optional
/ /
Date of birth:
Optional
Date(s) of Birth for Proposed Insured Person(s)
Required
Deductible
Optional
Deliver a Copy to You?
Optional
Delivery Preference To Holder
Optional


Hold down the Ctrl Key to make multiple selections.
Delivery To Holder Preference
Optional
Describe any claims/losses in the past 5 years
Optional
Describe any health problems
Optional
Describe any medical issues:
Optional
Describe items and value:
Optional
Describe Your Business
Optional
Describe:
Optional
Description Of Other Employee Work
Optional
Description of Work
Optional
Details of any medical conditions:
Optional
Do any of your vehicles have the following items?
Do you allow animals?
Optional
Do you have a cottage or secondary home?
Optional

Do you have any financing on your house?
Optional

Do you have any of the following?
Do you have children away at college?
Required

Do you have detached structures on your property?
Required

Do you operate a business or day care in your home?
Required

Do you own any of the following motorized items:
DO YOU OWN ANY RENTAL PROPERTIES?
Optional

Do you own or rent any farm land?
Optional

Do you rent any part of your home to others?
Required

Do you rent or own your residence?
Required
Do you rent to college students?
Optional
Do you use your vehicle in a ride service, such as Uber, Lyft, Sidecar, or others?
Optional

Do you want a quote for Earthquake coverage?
Required

Do you want a quote for flood insurance?
Required

Do you want a quote for life insurance?
Optional

Do you want a quote for umbrella liability?
Optional
Do you want coverage for earthquake damage?
Optional

Do you want coverage for flood damage?
Optional

Do You Want Identity Fraud Expense Coverage?
Optional

Do you want Rental Reimbursement on any vehicles?
Optional

Do you want to schedule jewelry or furs?
Optional

Does any household member have a pilot's license?
Optional

Does The Certificate Holder Need To Be Additional Insured?
Optional
Does your medical insurance cover you in a car accident?
Optional

Does your medical insurance EXCLUDE injuries from auto accidents?
Optional

Dollar Amount of Materials
Optional
Drawings/Specifications Prepared By:
Optional
Driver Employees Annual Payroll
Optional
Driver Four
Driver One
Driver Three
Driver Two
Driver's License Number
Optional
Driver's License Number
Optional
Driver's License Number
Optional
Driver's License Number
Optional
Drywall
Required
Drywall %
Optional
DVD or VCR?
Optional

Dwelling Information
Dwelling limit:
Optional
DWELLING STYLE
Optional
Ease of doing business with us
Optional
Education Level
Required
Education Level
Optional
Education Level
Optional
Education Level
Optional
Enter year, make, and model of vehicles to have Rental Reimbursement:
Optional
Extend Wage Loss benefit beyond 3 years?
Optional

Exterior Materials
List the % of each EXTERIOR WALL MATERIAL (total must = 100%)
Exterior Wall Materials (total must = 100%)
Face Amount Of Policy
Optional
Fax #
Optional
Federal Employer's Identification Number (FEIN)
Optional
Firearms: $10,000
Optional

Firearms: $2,000
Optional

Firearms: $2,000
Optional

Firearms: $2,000
Optional

Firearms: $2,000
Optional

Firearms: $2,000
Optional

Firearms: $3,000
Optional

Firearms: $3,000
Optional

Firearms: $3,000
Optional

Firearms: $5,000
Optional

FIREPLACE
Optional
Fireplaces
Optional
First Proposed Insured
List the % of each FLOOR COVERINGS MATERIAL (total must = 100%)
Floor Coverings
Floor Coverings (total must = 100%)
Floor Coverings (total must= 100%)
FOUNDATION
Optional
Friendly, courteous attitude
Optional
Garage # of stalls
Optional
Garage Type
Optional
Gender
Optional
Gender
Optional
Gender
Optional
Gender
Optional
General Information
General opinion of our phone system
Optional
General Questions
General Rating Of Our Agency
Guns worth over $2,000?
Required

Hardwood
Required
Hardwood %
Optional
Hardwood %
Optional
Have You Started Work On This Job?
Optional

Height:
Optional
Help Us Customize Your Coverage
Homeowners Insurance
Homeowners Insurance
Horsepower
Optional
How can we improve our service?
Optional
How can we improve our service?
Optional
How did you hear of our agency?
Required
How is vehicle used?
Optional
How is vehicle used?
Optional
How is vehicle used?
Optional
How is vehicle used?
Optional
How many licensed drivers in your household?
Required
How many years since tobacco last used?
Optional
Identity Fraud Expense
Optional
Identity Theft insurance will help cover certain expenses associated with restoring your credit following an incident of identity theft (it does NOT cover the actual loss of money caused by identity theft).
If business is new, describe owner's prior experience in this type of work and other business management/ownership:
Optional
If by referral, who referred you?
Optional
If camping trailer, is it kept in a park seasonally or towed to various destinations?
Optional

If no current policy, please tell us why:
Optional
If no, provide details:
Optional
If Other, please describe
Optional
If so, please provide description of items and appraised value of each
Optional
If yes, and you want additional coverage, what is the combined value of your silverware?
Optional
If yes, approximate value
Optional
If yes, approximate value of collection
Optional
If yes, Do you want your insurance to cover items that are lost or do you want more than $1,000 coverage?
Optional

If yes, indicate total value
Optional
If yes, please describe property (computers, faxes, tools, other equipment, etc.) and indicate total value below
Optional
If yes, please describe your business
Optional
If yes, please provide the following details
If yes, what is the approximate replacement cost?
Optional
If yes, what is the total value of all your guns?
Optional
If yes, where do they reside
Optional


If Yes, Which Policies to Add Additional Insured To?
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.
Contact our office immediately if any vehicles insured on your auto policy are not titled or leased to a "named insured".
If your home were destroyed, would it have to be rebuilt with more expensive materials or techniques in order to meet current building codes?
Required


Imported Ceramic Tile
Required
Increase Wage Loss above $5,452 per month?
Optional

Indicate and describe any of the following property you own
Optional



Indicate Any Special Provisions For Additional Insured
Optional
Info for Performance and Labor/Material Bonds
Information About Your Condo
Information About Your Home
List the % of each INTERIOR WALL COVERINGS (total must = 100%)
Interior Wall Coverings
Interior Wall Coverings (total must = 100%)
Interior Wall Coverings (total must = 100%)
Interior Wall Coverings (total must = 100%)
Interior Wall Materials
Interior Wall Materials (total must = 100%)
Interior Walls
List the % of each INTERIOR WALLS MATERIAL (total must = 100%)
Is Building Currently Occupied by Tenants?
Optional
Is your home in a flood zone?
Required

Jewelry & Furs (combined): $5,000
Optional

Jewelry & Furs worth over $1,000?
Required

Jewelry & Furs: $1,000
Optional

Jewelry & Furs: $10,000
Optional

Jewelry & Furs: $5,000
Optional

Jewelry & Furs: $5,000
Optional

Jewelry & Furs: $5,000
Optional

Knotty Pine Paneling
Optional
Knotty Pine Paneling
Required
Knotty Pine Paneling %
Optional
Knowledge of insurance products
Optional
Laminated Wood
Required
Laminated Wood %
Optional
Laminated Wood %
Optional
Landlord Liability limit:
Optional
Legal entity type
Optional
Length
Optional
Let us know...
License (State, Number)
Optional
Life Insurance
Life insurance protection
Lines Of Coverage Needed On Certificate
Optional



Lines Of Insurance Needed On Certificate
Optional



Liquidated Damages ($)
Optional
List all accidents and violations in last 5 years
Optional
List all at-fault accidents in last 5 years
Optional
List all claims in last 3 years
Optional
List all moving violations in the last 5 years
Optional
List all not at-fault accidents in last 3 years
Optional
List all other violations in last 3 years
Optional
List all violations, accidents, and claims in last 3 years
Optional
List all violations, accidents, and claims in last 3 years
Optional
List all violations, accidents, and claims in last 3 years
Optional
List all violations, accidents, and claims in last 3 years
Optional
List any health issues and any medications taken:
Optional
List any medications you currently take:
Optional
List any medications you take, including dosage:
Optional
List any other groups you belong to
Optional
List major violations in last 5 years
Optional
List major violations in last 5 years
Optional
List major violations in last 5 years
Optional
List major violations in last 5 years
Optional
List the names of likely beneficiaries
Optional
List year, make, model, hp/cc, and value for any items you own:
Optional
Location of work to be done
Optional
Loss Assessment Coverage Limit
Optional
Loss Of Rents limit:
Optional
Loss Of Use Limit
Optional
Loss Of Use limit:
Optional
Make
Optional
Make
Optional
Make
Optional
Make
Optional
Marble Tile
Required
Marble Tile %
Optional
Marble Tile %
Optional
Marital Status
Optional
Marital Status
Optional
Maximum speed
Optional
Medical Payments to Others Limit
Optional
Medical Payments To Others limit:
Optional
Medicare and Medicaid, as well as some other medical plans, do not cover car accidents. If you rely on one of these plans for medical insurance, it's important that PIP medical coverage on your auto policy is written as "Primary or Full" and not as "Excess".
Mini-Tort Coverage
Required
Miscellaneous Risks
Model
Optional
Model
Optional
Model
Optional
Model
Optional
Motorized Vehicle Risks
Name and Address of Obligee
Optional
Name of Driver (First, Last)
Optional
Name of Driver (First, Last)
Optional
Name of Driver (First, Last)
Optional
Name of person to be covered
Optional
Name of person to be insured:
Optional
Name of person to quote:
Optional
Name of person to quote:
Optional
Name of proposed insured person
Optional
Name of trust:
Optional
Note Any Special Features
Optional
Note Any Special Features of Your Condo
Optional
NOTE ANY SPECIAL FEATURES OF YOUR HOME
Optional
Notes
Optional
Notes:
Optional
Number of 1/2 Baths
Optional
Number of 3/4 Baths
Optional
Number Of Apartments In Your Building
Optional
Number of autos you own
Optional
Number of Boats you own
Optional
Number of Cars provided by your employer for your use
Optional
Number of Cars you own (including those owned by family members @ home)
Optional
Number of Condo Units in Your Building
Optional
Number of drivers under 25 years old
Optional
Number of Full Baths
Optional
Number of homes you own
Optional
Number of Homes/cottages you own
Optional
Number of Household drivers under age 23
Optional
Number of household members:
Required
Number of Kitchens
Optional
Number of Recreational vehicles you own
Optional
Number of rental dwellings you own
Optional
Number of Rental Dwellings you own
Optional
Number Of Rental Units in Building
Optional
Number of Stories
Optional
NUMBER OF STORIES
Optional
Number of Street cycles you own
Optional
Number of vehicles provided by your employer for your personal use
Optional
Number of years for level premium:
Optional
Number of Years for Maintenance/Warranty Period
Optional
Nylon/Acrylic Carpet %
Optional
Occupation
Optional
Occupation
Optional
Occupation
Optional
Occupation
Optional
Other
Required
Other %
Optional
Other %
Optional
Other %
Optional
Other %
Optional
Other Coverages Needed:
Optional
Other Features
Other Information
Other Information
Other Items
OTHER ITEMS
Optional







Other Questions
Other Structures Limit
Optional
Other Structures limit:
Optional
Our Recommended Minimum Limits
Paint
Required
Paint %
Optional
Paint %
Optional
Parquet %
Optional
Percentage of Job Sub-Contracted
Optional
Period For Level Premiums
Optional




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

Personal Injury Protection
Personal Injury Protection
Required

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).
Personal Injury Protection - Medical
Required
Personal Injury Protection - Work Loss
Required
Personal Liability limit:
Optional
Personal Property Limit
Optional
Personal Property limit:
Optional
Personal Property Special Limits
Phone system
Optional
Personal Injury Protection (PIP) is a required coverage for all vehicles registered in Michigan. PIP pays your medical bills if you are injured in a car accident and also pays to replace 85% of your gross income if you are disabled from a car accident. The wage loss coverage is subject to a current monthly maximum of $4,713 ($56,556/year) and a maximum 3 year time period.
Plaster
Required
Plaster %
Optional
Please describe, Provide dimensions, age and what it is used for.
Optional
Please elaborate on reasons noted above:
Optional
Please indicate any addresses and if we already insure property
Optional
Please Let Us Know...
Please provide details to any "yes" questions. Vehicle, type of equipment and value.
Optional
Please provide the following details for any of the above
Please Rate Our Services
Please Rate Our Services
Policy Holder Information
Porch
Optional
PRIMARY HEATING SYSTEM
Optional




Prior Address If Moved in Last 6 Months
Optional
Prior address if you moved in the last 6 months
Optional
Project Completion Date
Optional
/ /
Project Start Date
Optional
/ /
Property Damage Liability
Required
Property Damage Liability: $500,000 per accident Pays defense costs and judgement against you for property damage you've caused in a car accident outside Michigan.
Property Damage Liability: $500,000
Optional

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

Property Protection Insurance
Optional
Property used in your job or business and used or taken away from your home worth over $250?
Required

Property used in your job or business but kept at home over $2,500?
Optional

Protecting Human Assets
Quality of bathroom materials
Optional
Quality of Baths
Optional
Quality of Kitchen Materials
Optional
Quality of Kitchen(s)
Optional
Rate Our Agency Service...
Rate Our Service...
Rate Your Client Service Manager
Rate your main contact's helpfulness
Optional
Rating Classifications
Reason(s) for cancelling insurance (check all that apply):
Optional



Recommended Minimum Auto Insurance Limits
Our recommended MINIMUM limits for several coverages are shown below. Higher limits are available. Indicate if you accept these limits for your policy or not.
Rental Reimbursement
If yes, please complete the following for each vehicle you'd like Rental Reimbursement for
Rental Reimbursement Coverage
Rental Reimbursement Limit
Required
Rental Reimbursement Limit
Optional
Rental Reimbursement Limit
Optional
Rental Reimbursement Limit
Optional
List the % of each ROOF MATERIAL (total must = 100%)
Roof Materials
Roof Materials (total must = 100%)
Optional
Roof Materials (total must = 100%)
ROOM ADDITIONS
Optional
ROOM ADDITIONS
Optional
Rubber
Optional
Rugs, tapestries, wall hangings worth over $5,000?
Required

Safety Devices
Optional




Safety Devices
Optional




Safety Devices
Optional


Hold down the Ctrl Key to make multiple selections.
Safety Devices
Optional




Safety Devices
Optional




Sales Employees Annual Payroll
Optional
Second Proposed Insured
Second Proposed Insured
Securities & Stamps: $1,000
Optional

Securities & Stamps: $10,000
Optional

Securities & Stamps: $5,000
Optional

Securities & Stamps: $5,000
Optional

Securities & Stamps: $5,000
Optional

Securities or stamp collections worth over $1,000?
Required

Select Additional Condo Coverages desired:
Optional








Select Additional Coverages desired:
Optional







Select from below
Select from below...
Select group discount
Required
Select Rental Reimbursement limit:
Optional




Select the person you are evaluating
Optional
Select Your Coverages
Send A Copy To You?
Optional
Sheet Paneling
Optional
Sheet Paneling
Required
Sheet Paneling %
Optional
Shingles - Asphalt/Fiberglass
Optional
Shingles - Wood
Optional
Silverware worth over $2,500?
Required

Silverware: $1,000
Optional

Silverware: $1,000
Optional

Silverware: $1,000
Optional

Silverware: $10,000
Optional

Silverware: $2,500
Optional

Silverware: $2,500
Optional

Silverware: $2,500
Optional

Silverware: $2,500
Optional

Silverware: $2,500
Optional

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

Solid Wood Paneling
Required
Solid Wood Paneling %
Optional
Solid Wood Paneling %
Optional
Special Coverage Options
Special Features
Optional





Square Feet (or %) Finished in Basement
Optional
Square Feet Finished (excluding basement)
Optional
Square Footage
Optional
SQUARE FOOTAGE (OR %) FINISHED IN BASEMENT
Optional
SQUARE FOOTAGE FINISHED (excluding basement)
Optional
Square Footage of Decks
Optional
SQUARE FOOTAGE OF DECKS
Optional
Square Footage of Porch
Optional
State
Optional
Stereo equipment that is not permanently installed?
Optional

Stone
Required
Stone %
Optional
Tar and Gravel
Optional
Tell us how we can best meet your needs!
Optional
Tell us how we can best meet your needs!
Optional
Tell us how we can best meet your needs!
Optional
Tell us how we can best meet your needs!
Optional
Term for level premium:
Optional
Thank You! We appreciate your feedback.
The following categories of property are limited. Do you need more than the following amounts?
Timely response to phone calls or e-mails
Optional
Tin
Optional
Tongue & Groove Paneling
Optional
Tongue In Groove Paneling
Required
TOTAL FINISHED LIVING AREA (not including finished basement)
Required
Towing Limit
Optional
Towing Limit
Optional
Towing Limit
Optional
Towing Limit
Optional
Township
Optional
Township Located In
Optional
Trading cards (baseball card collections, etc.) worth over $1,000?
Required

Trading cards: $1,000
Optional

Trading cards: $250 per item/$2,500 maximum
Optional

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

Trailers not used with watercraft: $2,500
Optional

Trailers not used with watercraft: $2,500
Optional

Trailers not used with watercraft: $2,500
Optional

Trailers not used with watercraft: $3,000
Optional

Type
Optional




Type Of Collision Coverage
Required
Type of collision coverage
Required
Type Of Collision Coverage
Optional
Type Of Collision Coverage
Optional
Type Of Collision Coverage
Optional
Type Of Garage
Optional
Type of Heating System
Optional
Type of propulsion
Optional



Type of vehicle
Optional
Umbrella Liability
Umbrella Liability Insurance provides lawsuit protection in excess of auto, home, boat, and other underlying liability insurance and provides broader coverage in some instances.
Under-Insured Motorist: $500,000 per person/$500,000 per accident Pays what you're legally entitled to receive for your serious injuries sustained in a car accident caused by a driver with too little liability coverage to pay for your loss (an under-insured driver). This could include compensation for pain and suffering, wrongful death, permanent disability, and long-term loss of income.
Under-Insured Motorist - Bodily Injury
Required
Under-Insured Motorist: $500,000 per person/$500,000 per accident: Increase your policy to these limits?
Optional

Under-Insured Motorists: $500,000
Optional

Uninsured Motorist: $500,000 per person/$500,000 per accident Pays what you are legally entitled to receive for your serious injuries sustained in a car accident caused by an uninsured driver. This could include compensation for pain and suffering, wrongful death, permanent disability, and long-term loss of income.
Uninsured Motorist Bodily Injury
Required
Uninsured Motorist: $500,000 per person/$500,000 per accident: Increase your policy to these limits?
Optional

Uninsured Motorists: $500,000
Optional

Value
Optional
Value of Boat
Optional
Value of Motor, or leave blank to show it's included in value of boat
Optional
Value of trailer
Optional
Vehicles
Optional


VIN #
Optional
VIN #
Optional
VIN #
Optional
Vinyl
Required
Vinyl
Required
Vinyl %
Optional
Vinyl %
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Vinyl %
Optional
Wallpaper
Required
Wallpaper %
Optional
Wallpaper %
Optional
Water & Sump Pump Backup Coverage
Optional



Water Backup: Select the limit of coverage you want for damage caused by water that backs up in a floor drain or sump pump.
Required



Water/Sump Pump Backup - Select Limit
Optional
Water/Sump Pump Backup - Select Limit
Optional
Water/Sump Pump Backup - Select Limit:
Optional
Water/Sump Pump Backup Coverage
Optional
Watercraft & Equipment: $2,000
Optional

Watercraft & Equipment: $2,500
Optional

Watercraft & Equipment: $2,500
Optional

Watercraft & Equipment: $3,000
Optional

Watercraft and equipment: $1,000
Optional

Watercraft and equipment: $2,500
Optional

Weight:
Optional
What do you DISLIKE about our agency?
Optional
What do you LIKE about our agency?
Optional
What insurance company did you switch to?
Optional
What is your new premium?
Optional
What Were The Three Lowest Bids?
Optional
When was business established?
Optional
When was electrical last updated?
Optional
When was heating last updated?
Optional
When was plumbing last updated?
Optional
When was the last time you used tobacco?
Optional
Which vehicle does this driver use most?
Optional
Which vehicle does this driver use most?
Optional
Which vehicle does this driver use most?
Optional
Which vehicle does this driver use the most?
Required
Who did you work with most at our agency?
Optional


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Who Prepared Drawings/Specifications?
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Why are you shopping?
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Will a trust be a beneficiary?
Optional

Will this policy be owned by a trust?
Optional

Willingness to provide service and resolve issues
Optional
Within 1,000 feet of a fire hydrant?
Optional

Within 1,000 feet of a fire hydrant?
Required

Within 5 miles of a fire department?
Required

Within 5 miles of fire department?
Optional

Wood
Required
Wood %
Optional
Wool/Berber Carpet
Required
Wool/Berber Carpet %
Optional
Wool/Berber Carpet %
Optional
Would you like a premium estimate for life insurance to pay off your mortgage and/or provide for your family?
Required

Would you like a proposal for life insurance?
Optional

Would you like a quote for life insurance?
Optional

Would you like to know more about extending the PIP wage loss benefits described above to cover more than $4713/month?
Required

Would you like to know more about extending the PIP wage loss benefits described above to cover more than 3 years time?
Required

Year
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Year
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Year
Optional
Year
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Year Built
Optional
YEAR CONDO BUILT
Optional
Year Condo Built
Optional
Year Home Built
Required
Year of trailer
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YES?NO
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Your policy includes limits on the following categories of property. Do you need more than:
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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.

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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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