BWO Insurance Form | BenefitSource Insurance Services

BWO Quote Form

Name of Person Submitting the Form:*
First Last
Email of Person Submitting the Form:*
Phone of Person Submitting the Form:*
How did you hear about us?*
Quote Type*
Home Quote Form
Property Type*
- Home
- Condo
- Secondary
Property Address*
Street Address City State ZIP Code
Year Purchased*
Month
Day
Year
Year Built*
Month
Day
Year
Square Feet of Your Home?*
Has your Roof Been Updated?*
- Yes
- No
If so, when?*
Month
Day
Year
Has your Heating System been Updated?*
- Yes
- No
If so, when?*
Month
Day
Year
What kind of Plumbing is in your home?*
Do you have at least 100 AMP Circuit breakers and no fuses?*
Is Your Home Vacant of for Sale?*
- Vacant
- For Sale
- Neither
Is There Existing Damage to Your Home?*
- Yes
- No
Custom or Designer Materials In:
- Kitchen
- Bathrooms
Previous Address
If you have owned this property less than 3 years, what is your prior address?
Street Address City State ZIP Code
Relationship Status*
- Married
- Domestic Partner
- Single
- Divorced
- Widowed
- Widower
Date of Birth*
Month
Day
Year
Occupation*
If applicable, Spouse/Partner DOB
Month
Day
Year
Spouse/Partner Occupation
Any claims filed in the last 5 years?*
- Yes
- No
Describe nature and date of claim*
Any special High Value items you're concerned about? (Jewelry, art work, furs, etc)*
- Yes
- No
What Kind of High Value Items and What is the Value?*
Sprinkler system inside the home?*
- Yes
- No
If so, is the system:*
- Full
- Partial
Is the property in a gated community?*
- Yes
- No
If gated, is it guard gated?*
- Yes
- No
Burglar and Fire System Connection*
Are they connected to a monitoring company?
- Yes
- No
If yes, who is the monitoring vendor?*
Do you have any of the following?*
- Pool
- Jacuzzi
- Water Slide
- Diving Board
- Solar Panels
- None
How Many Solar Panels?*
Do you have any of the following?*
- Live-In Nanny
- Regular Service People
- Tree House
- Skate Board Ramps
- Homes Based Business
- Wood or Pellet Stove
- Farming Operations
- None
Do you have a trampoline?*
- Yes
- No
If so, does it have a safety net?*
- Yes
- No
Do you have dogs?*
- Yes
- No
If so, what breeds?*
Do you use this property for AIRBNB/VRBO or student housing for a college?*
Do you have any of the following polices?*
- Earthquake
- Flood
- Umbrella
- None
Term Life Insurance*
Do you have term life insurance outside your employer that is at least ten times your annual income?
- Yes
- No
If so, how long have you had the policy?*
Auto Quote Form
Driver Count*
How many drivers are insured on your policy?
Home Address*
Street Address City State ZIP Code
Driver #1
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #2
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #3
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #4
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #5
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Driver #6
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Age First Licensed*
Any driving violations or accidents? Explain*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Occupation*
Work/School Address*
Name of Business/School Street Address City State ZIP Code
Auto Identification
Insured Vehicles*
How many insured vehicles to you have on your auto insurance policy?
Vehicle #1
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #2
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #3
Year*
Make*
Model*
VIN #*
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #4
Year*
Make*
Model*
VIN #*
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #5
Year*
Make*
Model*
VIN #*
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
Vehicle #6
Year*
Make*
Model*
VIN #*
Approximate Purchase Date*
Month
Day
Year
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Miles Driven One Way to Work?*
Primary Driver*
First Last
General Vehicle Questions
Aftermarket Options*
Do you have additional aftermarket equipment?
- Yes
- No
If so, which auto, type of equipment, and value?*
Years With Provider*
How many years have you been with your current auto insurance company?
Do you have an umbrella insurance policy?*
- Yes
- No
Do you have an auto provided by your employer?*
- Yes
- No
Do you have a AAA membership?*
- Yes
- No
Term Life Policy*
Do you have term life insurance outside of your employer that is at least ten times your annual income?
- Yes
- No
If so, how long have you had the term life?*
Discount Questions
Student Drivers*
Do any drivers on your policy under the age of 25 attend school full time and carry a 3.0 or above GPA?
- Yes
- No
Attendance Proof*
If so, can you provide a copy of the report card as proof of this discount?
- Yes
- No
College Grads*
Do any drivers have a degree from a 4 year accredited college or university located in the U.S.?
- Yes
- No
Graduation Proof*
Would you be able to provide a copy of the degree for the discount?
- Yes
- No
If so, list who, school name, and degree type:*
Rental Property Form
Property Address*
Street Address City State ZIP Code
Is the mailing address the same as the property address?*
- Yes
- No
Mailing Address*
Street Address City State ZIP Code
Year Purchased*
Owned Less Than 5 Years
If you have owned less than 5, what is your prior address?
Street Address City State ZIP Code
Do you have an HOA?*
- Yes
- No
Relationship Status*
Your Date of Birth*
Month
Day
Year
Your Occupation*
Your spouse/partner Date of Birth*
Month
Day
Year
Their Occupation*
Is there a tenant?*
- Yes
- No
If yes, are they full time or part time?*
Property Use*
- Yes
- No
Is the property used as a seasonal rental, such as AirBNB, Home Away?
Do you have a property management company?*
- Yes
- No
Is the property in a Trust, LLC, Corp or Partnership?*
- Yes
- No
Any Claims filed in last 5 years?*
- Yes
- No
If yes, describe and list approximate date:*
Do you have a Sprinkler System inside you home?*
- Yes
- No
If so, is the system:*
- Full
- Partial
Is the property located in a Gated Community?*
- Yes
- No
If gated, is it guard gated?*
- Yes
- No
Do you have any of the following?*
- Pool
- Jacuzzi
- Both
Do you have Earth Quake insurance?*
- Yes
- No
Do you have Flood insurance?*
- Yes
- No
Renter's Form
Property Address*
Street Address City State ZIP Code
Your Date of Birth*
Month
Day
Year
Select your personal property amount of coverage:*
Do you have any Jewelry that should be insured?*
- Yes
- No
If yes, describe and list its value:*
Do you have dogs?*
- Yes
- No
If so, what breeds?*
Any High Value items you’re concerned about?*
- Yes
- No
What Kind of High Value Items and What is the Value?*
Are there any special items that you're concerned about?*
- Yes
- No
Are you required to provide proof of insurance to your property manager?*
- Yes
- No
Motorcycle/ATV Form
How many Driver's operate your Motorcycle/ATV?*
Home Address*
Street Address City State ZIP Code
Driver #1
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any driving violations or accidents?*
- Yes
- No
Driver #2
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any driving violations or accidents?*
- Yes
- No
Driver #3
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any driving violations or accidents?*
- Yes
- No
Driver #4
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any driving violations or accidents?*
- Yes
- No
Driver #5
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any driving violations or accidents?*
- Yes
- No
Driver #6
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any driving violations or accidents?*
- Yes
- No
Motorcycle/ATV Identification
How many Motorcycle/ATV's need insured?*
Motorcycle/ATV #1
Year*
Make*
Model*
VIN #*
Number of CC's*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #2
Year*
Make*
Model*
VIN #*
Number of CC's*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #3
Year*
Make*
Model*
VIN #*
Number of CC's*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #4
Year*
Make*
Model*
VIN #*
Number of CC's*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #5
Year*
Make*
Model*
VIN #*
Number of CC's*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV #6
Year*
Make*
Model*
VIN #*
Number of CC's*
Miles Driven Per Year*
Primary Driver*
First Last
Motorcycle/ATV General Questions
Do you have additional aftermarket equipment?*
- Yes
- No
If so, how much aftermarket equipment?*
Do you have an Umbrella insurance policy?*
- Yes
- No
Boat Form
Home Address*
Street Address City State ZIP Code
Year*
Make*
Model*
Hull #*
Length*
Motor Style
- Inboard
- Outboard
Horse Power*
Cost New*
Current Value*
Do you have separate towing coverage?*
- Yes
- No
Do you have scheduled equipment?*
- Yes
- No
Years of Operating Experience:*
Do you have any marine certifications?*
- Yes
- No
Where is it stored?*
Street Address City State ZIP Code
Is it stored in a secured or fenced in area?*
- Yes
- No
Motor Home/Travel Trailer Form
How many Driver's operate your Motor Home?*
Home Address*
Street Address City State ZIP Code
Driver #1
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any Driving violations or accidents?*
- Yes
- No
Driver #2
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any Driving violations or accidents?*
- Yes
- No
Driver #3
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any Driving violations or accidents?*
- Yes
- No
Driver #4
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any Driving violations or accidents?*
- Yes
- No
Driver #5
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any Driving violations or accidents?*
- Yes
- No
Driver #6
Name*
First Last
Date of Birth*
Month
Day
Year
Driver's License #*
Sex*
- Male
- Female
Marital Status*
- Married
- Unmarried
- Widowed
- Widower
Age First Licensed*
Any Driving violations or accidents?*
- Yes
- No
Motor Home/Travel Trailer Identification
Number of Motor Home/Travel Trailer needing insured?*
Motor Home/Travel Trailer #1
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #2
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #3
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #4
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #5
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer #6
Year*
Make*
Model*
VIN #*
Use*
- Commute
- Pleasure
- Business
Miles Driven Per Year*
Primary Driver*
First Last
Motor Home/Travel Trailer General Questions
Do you have additional aftermarket equipment?*
- Yes
- No
If so, how much what kind of aftermarket equipment?*
Where is this stored?*
- Primary Home
- Other
If "Other" list address:*
Street Address City State ZIP Code
Do you have an Umbrella insurance policy?*
- Yes
- No
Current Odometer*
General Document Uploads
Files
This is where you can upload your insurance declarations pages and any other relevant documents that are necessary for your quote request.
Drop files here or
Max. file size: 256 MB.
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BWO Quote Form

Home Quote Form

Auto Quote Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Auto Identification

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Vehicle #6

General Vehicle Questions

Discount Questions

Rental Property Form

Renter's Form

Motorcycle/ATV Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Motorcycle/ATV Identification

Motorcycle/ATV #1

Motorcycle/ATV #2

Motorcycle/ATV #3

Motorcycle/ATV #4

Motorcycle/ATV #5

Motorcycle/ATV #6

Motorcycle/ATV General Questions

Boat Form

Motor Home/Travel Trailer Form

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Motor Home/Travel Trailer Identification

Motor Home/Travel Trailer #1

Motor Home/Travel Trailer #2

Motor Home/Travel Trailer #3

Motor Home/Travel Trailer #4

Motor Home/Travel Trailer #5

Motor Home/Travel Trailer #6

Motor Home/Travel Trailer General Questions

General Document Uploads