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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 Condominium
    Owners Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!
    Your Personal Data:
     
    Your Name:
    Property Address:
    City:
    State: (Must be Minnesota)
    Zip/Postal:
    E-Mail (REQUIRED):
    E-Mail (again for accuracy):
    Phone:
    Fax (optional):
     
    Dwelling Information
     
    Year Dwelling Built:
    Home Square footage:
     
    # Units in common bldg.:
     
    Type Roof: Shingle Wood Shake
    Tar/Gravel Spanish Tile
     
    Number of stories: One Two
    Three 4+
     
    Do you own animals or pets? Yes No
    If yes, list type/for dogs, list breed:
     
    Are You Near Brush Area? Yes No
     
    # of feet to nearest
    fire hydrant:     		# of miles to nearest
    fire station:
     
    Currently Insured? Yes No
    Name of Carrier & how long insured?
     
    Prior Claims? Yes No
    Describe claims in detail:
     
    Plumbing type: Copper Galvanized
    Mixed (Copper/Galvanized)
     
    Circuit Breakers or fuses? Breakers Fuses


    # Fireplaces: # Chimneys:
     
    Special features
    (i.e., deck, air conditioning, alarm systems, pool, etc.)
     
    Coverages:
     
    Contents $ Loss of Use $
    Liability Cov. $ Deductible $
    ($250, $500, $1,000, etc.)
     
    Comments/Remarks
    (describe any scheduled jewelry, in-home business, or other special coverages needed here):
     
    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.

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