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Insuring Minnesota
20960 Holyoke Ave
Lakeville, MN 55044
Phone: 952-469-0425
Fax: 952-469-1881

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info@insuring
minnesota.com

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Underwriting Information
* Company Name
* Your First Name
* Last Name
* Email
* Email address (retype)
* Street Address
* City
* County
*
* Zip

* Phone (Day) Ext.

Phone (Evening)

Fax
 
About Your Business
Sole Proprietor Partnership Corporation LLC Association
Do you currently have Professional Liability Owners insurance? *
Yes No
Number of Owners or Officers?
If "Yes", when does your current policy expire?
If "Yes", who are you currently insured with?
Type of Business *
Description of Business Operations:
Do you currently have Business Liability Owners insurance?
Yes No
Year Business Established
Number of Locations
Number of Employees
Approximate Annual Gross Revenue *
Approximate Amount of Desired Insurance
Has your company submitted any claims in the last 3 years? *
Yes No
If "Yes", briefly explain:
 
Optional coverage (check the ones you may want)
Group Health Business Property
Business Owners Life
Workers Compensation Group Health
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