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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

    • Homeowners Insurance
    Quotation Form
    One Simple Form - takes only 2-3 Minutes!
    Your Personal Data:
     
    Your Name:
    Property Address:
    City:
    Your "County" is?
    State: (Must be Minnesota)
    Zip/Postal:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    Phone:
    Fax (optional):
     
    Primary Policyholder's Birthdate:
    (REQUIRED - Some companies products
    offer discounts for certain age groups.)
     
     
    Dwelling Information
     
    Year Home Built:
    Home Square footage:
     
    Is this Builder's Risk?
    (new home constr.)         		NO YES
     
    Month/Year home
    to be complete:
     
    Number of units: 1 family Duplex
     
    Type foundation: Basement
    Slab
    Crawlspace over slab
    Other (list in remarks)
    (If basement, what % is finished?)
    % FINISHED
     
    Type Construction: Frame
    Brick/Veneer
    Stone
    Other (list in remarks)
     
    Type Roof: Shingle
    Wood Shake
    Tar/Gravel
    Spanish Tile
    Metal Other
     
    Number of stories: One 1.5
    Two Three
     
    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:
     
    Does Home Have a Garage? Yes No
    Tell whether built in, detached/attached, and how many cars?
     
    Currently Insured? Yes No
    Name of Carrier & how long insured?
     
    Prior Claims? Yes No
    Describe claims in detail:
     
    Rate Your Credit History and Past Insurance Payment History:
    (Some companies products are
    based on your credit and payment history.)     		Excellent Fair
    Poor Horrible
     
    Plumbing type: Copper Galvanized
    Mixed (Copper/Galvanized)
     
     
    Heating Type: Gas (Propane or natural)
    Electric
    Oil (if oil, list tank location in remarks)
     
    Circuit Breakers or fuses? Breakers Fuses

    # Bedrooms: # Bathrooms:
     
    # Fireplaces: # Chimneys:
     
    Special features
    (i.e., deck, air conditioning, alarm systems, pool, etc.)
     
    Coverages:
     
    Dwelling Cov. $ Contents $
    Liability Cov. $ Deductible $
    ($250, $500, $1,000, etc.)
     
    Comments/Remarks
    (describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):
     
    Send my quotation via: E-Mail Fax
    Regular Mail
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