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  Gerry Smith Insurance Agency
12280 Nicollet Ave, Suite 104
Burnsville, MN 55337-1999

Ph  (952) 224-7029
Fax (952) 224-0400
gsmith@mnchoiceinsurance.com

 

 
 
Minnesota Car Insurance Quote Inquiry Form
This inquiry form will allow us to provide you with an automobile insurance cost and coverage summary, based on the information that you enter below. 

Note: This is not an application for insurance coverage.  

We recommend that you have a current copy of your insurance policy or declarations page to refer to as you are completing this form. When you have finished entering your information, click the 'Submit' button at the bottom of the page.

PERSONAL  INFORMATION

First Name   MI  
Last Name
Address
City
State
Zip Code

Disclaimer
To provide an accurate quote we will ask you a series of questions, some of which we will confirm through consumer reports which may include credit information. This information will be available to our representatives only. For more information, see our Privacy Statement. Do you want to continue?

I have read the disclaimer and want to continue: Yes No 

DRIVER INFORMATION

  Driver One Driver Two Driver Three Driver Four
First Name
Last Name
Birth Date
Gender
Male Female
Male Female
Male Female
Male Female
Marital Status
  
Single         Married   
 
Single        Married   
Single         Married   
Single        Married   
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Relationship to Driver One

Dr Lic #

State of Lic
Yrs Licensed

 

DRIVING HISTORY

List all moving violations and claims in the past 5 years

  Incident 1 Incident 2 Incident 3 Incident 4
Driver  One Mo/Yr  Mo/Yr  Mo/Yr  Mo/Yr
Driver Two Mo/Yr  Mo/Yr  Mo/Yr  Mo/Yr 
Driver Three Mo/Yr  Mo/Yr  Mo/Yr  Mo/Yr 
Driver Four Mo/Yr  Mo/Yr  Mo/Yr  Mo/Yr 
 

VEHICLE INFORMATION

  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Year
Make
Model
Style
(i.e. 2dr, XLT, 4wd)
Anti-Lock Brakes
Yes     No
Yes     No
Yes     No
Yes     No
Anti-Theft Device
Yes     No
Yes     No
Yes     No
Yes     No
Safety Features
Primary Driver
Vehicle Usage
Miles One
Way To Work/School
Annual Mileage
 

LIABILITY COVERAGES

Personal Liability
Bodily Injury $                                     Property Damage $
Uninsured/Underinsured Motorist $
Personal Injury Protection
 

ADDITIONAL COVERAGES

  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comprehensive
Collision
Full Glass
Yes     No
Yes     No
Yes     No
Yes     No
Towing
Yes     No
Yes     No
Yes     No
Yes     No
Rental Car
Yes     No
Yes     No
Yes     No
Yes     No

 

INSURANCE  INFORMATION

Current Insurance Company
Length of Continuous Insurance
Renewal/Expiration Date

 

CONTACT  INFORMATION

Preferred Method of Contact
 
E-mail
Daytime Phone Number
Fax Number
Postal Mailing Address
Questions or Comments
 

Please press the Submit button.
Wait a few moments for an online acknowledgment.

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