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55044

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On-Line Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name (first & last):
Street Address:
City:
State: (Must be Minnesota)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Our Minnesota Insurance Companies Require 6 Months of Prior Auto Insurance and a Reasonable Record.
(Please list your current insurance carrier and # of years continuous car insurance coverage.)
 


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): Social
Security #:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Education: Occupation:
Senior Defensive
Driver Course?
Yes No Minnesota Driver's
License #:


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: Social
Security #:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Education: Occupation:
Senior Defensive
Driver Course?
Yes No Minnesota Driver's
License #:
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:


VEHICLE #1 INFORMATION
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Full Glass
Coverage?
YES NO
 
Rental Car &
Towing Coverage?
YES NO
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits - - - Liability Limits Must
Match Vehicle #1 - - -
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Full Glass
Coverage?
YES NO
 
Rental Car &
Towing Coverage?
YES NO
 
Comments or Remarks:
(List additional drivers, autos, etc. here)
If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:


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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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