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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 Commercial
    Vehicle Quote Form
    One Simple Form - takes only 2-3 Minutes!
    YOUR PERSONAL DATA:

    Your Name:
    Business Name:
    Street Address:
    City:
    State: (Must be Minnesota)
    Zip/Postal:
    E-Mail (REQUIRED):
    E-Mail (Again, for Accuracy):
    Phone:
    Fax (optional):
     
    Currently Insured?
    (If yes, list carrier, and # of years
    continuous. If no, type NONE)
     
    Type of Business:
    (Please be specific, and
    tell how vehicles are used.)

     
    DRIVER INFORMATION #1
    (if more than two drivers,
    list in remarks)
    Name: Birthdate:
    Sex: # Years U.S.
     Auto License:
    Number & Type of
    Accidents within
    last 3 years:    		 Number & Type of
    MINOR violations within
    last 3 years:
    Number & Type of
    MAJOR violations within
    last 3 years:    		 Daily commute
    in ONE WAY miles:
    Does Driver need
    an SR22 FILING?    		 Yes No Comments or
    Remarks?
     
    DRIVER INFORMATION #2 (if none, leave blank)
    Name: Birthdate:
    Sex: # Years U.S.
     Auto License:
    Number & Type of
    Accidents within
    last 3 years:    		 Number & Type of
    MINOR violations within
    last 3 years:
    Number & Type of
    MAJOR violations within
    last 3 years:    		 Daily commute
    in ONE WAY miles:
    Does Driver need
    an SR22 FILING?    		 Yes No Comments or
    Remarks?

    COMMERCIAL VEHICLE #1:
    If more than 2 vehicles, list in remarks
    or call us at: 800-972-4292 ext. 425
    Year of vehicle: Make & Model:
    Type (truck, tow-truck, bobtail, etc.): Length in Feet:
    Gross Vehicle Weight: Cost
    New: $
    Radius of operation: Value $:
    List Special Equipment & Values
    (i.e., rack, tool box, etc.)

    VEHICLE ID#
    (highly suggested for accurate rating)

    VEHICLE #1 COVERAGES:
    Limits of
    Liability:    		 $500,000 CSL
    $750,000 CSL
    $1 Million CSL
     
    Comprehensive
    & Collision:    		 NO Coverage $250 Deductible
    $500 Deductible $1000 Deductible
     
    Do you want
    Medical Coverage?    		 Yes No   Uninsured
      Motorists?    		 Yes No
     
    COMMERCIAL VEHICLE #2:
    Year of vehicle: Make & Model:
    Type (truck, tow-truck, bobtail, etc.): Length in Feet:
    Gross Vehicle Weight: Cost
    New: $
    Radius of operation: Value $:
    List Special Equipment & Values
    (i.e., rack, tool box, etc.)

    VEHICLE ID#
    (highly suggested for accurate rating)


    VEHICLE INFORMATION FOR UNITS #3-5:
    (If none, Leave Blank)
    VEHICLE #3
    (List Year, Make, Model & Value)
    VEHICLE #4
    (List Year, Make, Model & Value)
    VEHICLE #5
    (List Year, Make, Model & Value)

    VEHICLE #2 - #5 COVERAGES:
    Limits of
    Liability:    		 $500,000 CSL
    $750,000 CSL
    $1 Million CSL
     
    Comprehensive
    & Collision:    		 NO Coverage $250 Deductible
    $500 Deductible $1000 Deductible
     
    Do you want
    Medical Coverage?    		 Yes No   Uninsured
      Motorists?    		 Yes No
     
    Send my quotation via: E-Mail Fax
    Regular Mail
    Call Me by Phone

     
    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.

    Yes, I Agree. Please Send Me a
    Commercial Vehicle Quote NOW!

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