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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
DRIVER INFORMATION
#1
Name:
Birthdate:
Sex:
Minnesota Drivers License #:
Cycle
Safety Course?
Social Security Number:
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:
Years U.S. Cycle License:
Does
Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
DRIVER INFORMATION
#2 (if none, leave
blank)
Name:
Birthdate:
Sex:
Minnesota Drivers License #:
Cycle
Safety Course?
Social Security Number:
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:
Years U.S.
Cycle License:
Does
Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
VEHICLE #1
INFORMATION
Year of
vehicle:
Make &
Model:
Is this a
4 Wheeler?:
If Yes,
Describe:
Vehicle Identification Number - VIN:
# of CC's:
Value of
Bike:
$
Special
Equipment Value:
$
VEHICLE #1
COVERAGES:
Limits
of Liability:
$15/30 BI / 10 PD $25/50 BI /
15 PD $50/100 BI / 50 PD $100/300 BI
/ 50 PD
Comprehensive &
Collision:
NO Coverage $250
Deductible $500 Deductible $1000
Deductible
Do you
want Medical Coverage?
Yes No
Uninsured Motorists
Cov.?
Yes No
VEHICLE #2 INFORMATION
(if none, leave blank)
Year of
vehicle:
Make &
Model:
Is this a
4 Wheeler?:
If Yes,
Describe:
Vehicle Identification Number - VIN:
# of CC's:
Value of
Bike:
$
Special
Equipment Value:
$
VEHICLE #2
COVERAGES:
Limits
of Liability:
$15/30 BI / 10 PD $25/50 BI /
15 PD $50/100 BI / 50 PD $100/300 BI
/ 50 PD
Comprehensive &
Collision:
NO Coverage $250
Deductible $500 Deductible $1000
Deductible
Do you
want Medical Coverage?
Yes No
Uninsured Motorists
Cov.?
Yes No
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quotation via:
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Phone
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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
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other purposes. By checking the box below you agree to
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method you have chosen, and to release us from any
liability should this information be accidentally viewed
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privacy.
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