Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute
in ONE WAY miles:
Senior Defensive
Driver Course
Yes
No
Minnesota Driver's
License #:
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birth date:
Sex:
Social
Security #:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute
in ONE WAY miles:
Senior Defensive
Driver Course?
Yes
No
Minnesota Driver's
License #:
If More than 2 Drivers, list Additional Driver's Names, Birth dates, and driving record history here:
VEHICLE #1 INFORMATION
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:
Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
Select Comprehensive Deductible:
Select Collision Deductible:
Full Glass
Coverage?
YES
NO
Rental Car &
Towing Coverage?
YES
NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:
Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits
- - - Liability Limits Must
Match Vehicle #1 - - -
Select Comprehensive Deductible:
Select Collision Deductible:
Full Glass
Coverage?
YES
NO
Rental Car &
Towing Coverage?
YES
NO
Comments or Remarks:
(List additional drivers, autos, group discounts, etc. here)
If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records 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.
Yes, I Agree.
Please Send Me a Minnesota Car Insurance Quote NOW!
Click Button Below When Done
Please Click Only Once . . . May take up to 30 seconds!
