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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 Liquor Liability
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!
    Your Personal Data

    Your Name:
    Business Name:
    Property Address:
    City:
    State: (Must be Minnesota)
    Zip/Postal:
    E-Mail (REQUIRED):
    Phone:
    Fax (optional):
     
    Underwriting Information
     
    Date Coverage Needed:
     
    Prior Carrier:
     
    Describe Business:
     
    Gross Annual Receipts: $
     
    Gross Liquor Receipts Only: $
     
    Square Footage of
    Your Business Location:         		$
     
    Number of Employees:
     
    Prior Claims? Yes No
    Describe claims in detail:
     

    Limits & Coverages:
    Liability Limits: $100,000    $300,000
    $500,000    $1 Million
    Option for $2 Million or more
     
    Comments/Remarks:
     
    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 release this information via the method you have chosen, and to release us any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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