Insured Name

Spouse

Address                                                                      City                                               State          Zip

Phone (H)                                            Phone (W)                                         Phone (Cell)

E-mail

How would you like to be contacted: Email; Phone (work or home); Mail? 

When is the best time to be contacted:  

For the fastest and most accurate business insurance quote, please provide as much information as possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

Auto Insurance

Auto    Truck   Recreational

1. Driver Name  

Date of Birth    Drivers License Number  

Marital Status   Married Single    Relation to you   

Vehicle Driven   

2. Driver Name  

Date of Birth    Drivers License Number  

Marital Status   Married Single    Relation to you   

Vehicle Driven   

3. Driver Name  

Date of Birth    Drivers License Number  

Marital Status   Married Single    Relation to you   

Vehicle Driven   

4. Driver Name  

Date of Birth    Drivers License Number  

Marital Status   Married Single    Relation to you   

Vehicle Driven   

5. Vehicle Year     Make      Model   

Vin#  

Name On Title Driven For:  

Comprehensive Coverage   Yes No   Deductible:   250   500   1000

Collision Coverage: Yes No     Deductible:   250   500   1000

6. Vehicle Year     Make      Model   

Vain#  

Name On Title Driven For:  

Comprehensive Coverage   Yes No   Deductible:   250   500   1000

Collision Coverage: Yes No     Deductible:   250   500   1000

7. Vehicle Year     Make      Model   

Vin#  

Name On Title Driven For:  

Comprehensive Coverage   Yes No   Deductible:   250   500   1000

Collision Coverage: Yes No     Deductible:   250   500   1000

8. Vehicle Year     Make      Model   

Vin#  

Name On Title Driven For:  

Comprehensive Coverage   Yes No   Deductible:   250   500   1000

Collision Coverage: Yes No     Deductible:   250   500   1000

9. Coverage Needed:

Bodily Injury/Property Damage Liability Limits   

Personal Injury Protection:    

Uninsured/Underinsured Limits:

Towing/Rental/Other:   

10. Discounts: Good Student/Defensive Driving   YES NO

11. Claims/ Accidents (Past 3 years): Driver: Date:

12. Do you own your own home or do you rent?   Own Rent

13. Current Insurance Company:    Effective Date:

14. To provide you with a more accurate report, I will need your permission to send for a consumer report. This includes the following:

    1. Motor Vehicle Report: This includes any violations on your driving record

    2. Clue Report: Which includes your claim history.

    3. Credit Score: This is not a Credit Report but gives us a determination factor to rate you in the correct class.

I (we) authorize Bowerman Insurance Agency and others acting on their behalf or at their direction, to obtain a consumer report for insurance purposes only. To obtain this information, we will need your social security numbers. This information will be kept confidential.

YES   NO    Name:    Date:

An agent will contact you to obtain details necessary to provide an accurate insurance quote.  Please provide any addition information that you think might be helpful or put any questions you would like answered. We appreciate the opportunity to provide a quote on your insurance.

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PROPERTY INSURANCE

1. House Information

Property Location:

Year Built:     Dimensions/SQ Feet:

Type of House: 1 Story 1.5 Story 2 Story    Ranch Split Level Other

Construction: Framed    Masonary or Brick    Mobile Home     Apartment    Condo

                         Other

Updates (need year/type)   Shingles: Type    Electrical

Plumbing Heat   Type:

Basement: Yes No    Dimensions/Square Feet:  Finished Yes No

Deck/Porch/Balcony: Yes No   Dimensions

Garage: Attached Unattached    Dimensions 

Updates (need year):   Shingles Yes No  Type

Other Structures (Unattached)   Dimensions:

Updates (need year):   Shingles Yes No  Type

Coverage Requested: Dwelling  Other Structures

Personal Property      Additional Living  

Liability     Medical Payments

Claim History: (Past 3 years)

Nearest Fire Department:   Miles      Blocks   

Current Insurance Company:      Effective Date:  

An agent will contact you to obtain details necessary to provide an accurate insurance quote.  Please provide any addition information below that you think might be helpful or put any questions you would like answered below. We appreciate the opportunity to provide a quote on your insurance.

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Farm/Crop Insurance

Due to the complexity of coverage please call us at the number or e-mail listed or let us contact you.

Phone: 701-475-2340 or 800-435-0310
e-mail: bowins@bektel.com

Contact Me

Commercial/Business Insurance:

Name of Business:   

Please describe what type of business you operate:  

Type of Coverage you need:

Bond     Commercial Auto    Commercial Liability    Commercial Property

Commercial Umbrella    Professional Liability    Contractors   Other

Group Health

About Your Business:

# of Employees    # of part time employees  

How long in business?     How many locations?  

Annual Sales/Payroll:  

Claim History (past 3 years)

Nearest Fire Department:   Miles:     Blocks:  

Current Insurance Company:     
Effective Date:

An agent will contact you to obtain details necessary to provide an accurate commercial insurance quote.  Please provide any addition information that you think might be helpful or put any questions you would like answered . We appreciate the opportunity to provide a quote on your insurance.

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Health Insurance

What type of insurance do you need?

Health/Medicare/Long Term Care Insurance

Life/Health/Supplemental/Disability/LTC Insurance

Answer the following nine questions for all types of listed insurance

Name:       Male or Female

Date Of Birth     Age:   

Tobacco Use:   Yes or No

Medical/Health Condition (if any): Above Average Average Fair

Surgeries (if any):   

Medications (if any):

If married does spouse have health ins coverage? Yes No

If yes, is it Group or Personal ?

Additional Covered Persons:

 A. Spouse

    Name:   Male or Female

    DOB:      Age:  

    Tobacco Use:   Yes or No

    Medical Conditions (if any):   

    Surgeries (if any):  

 B. Children:

      Name:    Male or Female

      Date Of Birth     Age:   

      Tobacco Use:   Yes or No

      Medical Conditions (if any):   

      Surgeries (if any):  

 C. Children:

      Name:    Male or Female

      Date Of Birth     Age:   

      Tobacco Use:   Yes or No

      Medical Conditions (if any):   

      Surgeries (if any):  

 D. Personal Health Insurance Policy in force Yes or No

       Company:   

       Type of Policy (Plan Type):       
       Effective Date:  

       Occupation:

       Explain if necessary:
       

       Life Insurance:  Yes or No

       Life Insurance Amount:    Riders/Benefits:  

       Plan: Term Whole Universal Other  

       Disability: If Business, is it a partnership, corporation, ect?  

       Monthly/Annual Income:

       Medical Supplemental:   Yes or No

       Long Term Care:   Yes or No