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    Minnesota Insurance Center.com
    PO Box 1177 Lakeville, MN 55044
    Phone: 952-469-0425 | Fax: 952-469-1881
    Email Us Your Questions: Customer Service
    •  
    On-Line Automobile
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!
    Your Personal Data

    Your Name:
    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
     
    Currently Insured?
    (If yes, list carrier, and # of years
    continuous. If none, type N/C)

    DRIVER INFORMATION #1
    Name: Birthdate:
    Sex (M/F): # Years U.S.
     Licensing:
    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:
    Does Driver need
    an SR22 FILING?    		 Yes No If YES to SR22 filing, why needed?
    (list accident/cite)

    DRIVER INFORMATION #2 (if none, leave blank)
    Name: Birthdate:
    Sex: # Years U.S.
     Licensing:
    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:
    Does Driver need
    an SR22 FILING?    		 Yes No Comments or
    Remarks?
    If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

    VEHICLE #1 INFORMATION
    (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
    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:
     
    Uninsured Motorists
    Coverage?    		 YES NO
     
    Rental Car &
    Towing Coverage?    		 YES NO
     
    Medical and/or
    PIP 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:
     
    Uninsured Motorists
    Coverage?    		 YES NO
     
    Rental Car &
    Towing Coverage?    		 YES NO
     
    Medical and/or
    PIP 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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    Thank you for filling out this form COMPLETELY!

    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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