BOIA - Business Owner's Insurance Agency, Inc.

Homeowner's - Renter's Insurance Quote

What is your first name?

What is your last name?

What is the ZIP code of the property you wish to be quoted?

Will this insurance replace an existing policy?

Yes No

Insurance Information

Tell us the name of your most current insurance company:

What date does your current policy expire / renew?:

How long have you been insured with your current insurance company?

yearsmonths

How long have you had this property continuously insured?

yearsmonths

Residence Information

Address of the property to be quoted:

Address 2 or Apt. Number:

City / Township:

County / Parish:

State:

ZIP Code:

Please select the property type:

Do you currently own (or are you in the process of purchasing) this property?

Yes No

Do you now reside, or plan on residing at this property within the next 12 months?

Yes No

Property
Please enter some basic insurance information about this property. Be as accurate as possible.
Note: Based on your answers on the previous page, you will be quoted for a dwelling policy. Standard levels of other coverages not listed will be included in the policy quotes based on your state and answers to the questions below

How much Residence coverage do you want? (In dollars; for example: 250,000)

How much personal liability coverage do you want?

Approximate year property built?

Approximate livable square footage of residence: (excluding basement, if any)

Is this your primary or secondary residence?

Have you reported any claims or losses to your insurance company within the past 5 years?

Yes No

Is business or farming conducted on this property?

Yes No

Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or mix of these?

Yes No

Dwelling design:		Exterior wall type (60% or more):
Number of bedrooms		Number of bathrooms:

In some cases we have pre-selected the most common answers to the questions below. Please adjust as necessary.

Roof type:		Roof age:
Garage type:		Describe Foundation or Basement:
Wiring type:		Service panel type:
Burglar Alarm:		Central Fire Alarm:
Fire station:		Fire hydrant:
Municipal location:
Please describe the heating system in this dwelling:
Number of gas, pellet or wood fireplaces or stoves:
Is your home prone to flooding or located in a designated flood plain?

Property Accessories (Check all that apply)

Dead Bolts	Air Conditioning	Swimming Pool	Smoke Detectors	Covered Deck / Patio
Tennis Court	Fire Extinguisher	Uncovered Deck / Patio	Trampoline	Indoor Fire Sprinkler

Homeowner

Owner's First Name:		Owner's Last Name:
Owner's Date of Birth:		Owner's Gender:	Male Female
Owner's Social Security Number:	(Optional but helpful)
Co-Owner's First Name:		Co-Owner's Last Name:
Co-Owner's Date of Birth:		Co-Owner's Gender:	Male Female
Co-Owner's Social Security Number:	(Optional but helpful)
How would you (owner) describe your credit rating?		Poor Good Excellent Unsure

First Name:		Last Name:
Street Address:		Apt or Unit
City:		County / Parish:
State:		ZIP Code:
Current residence status:
Years/months at current residence?	years months
Please enter a valid Email address:
Home Telephone Number:
Daytime Telephone Number:
Are you interested in a multi-policy discount (for auto and home insurance)?		Yes No

DISCLOSURE: Where permitted by law, some insurance companies may confirm your information, through the use of consumer reports, which may include credit score and driving record.