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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 Life Insurance Quote Inquiry Form
This inquiry form will allow us to provide you with a life 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

APPLICANT INFORMATION

Applicant Spouse / Co-Applicant
First Name
Last Name
Gender Male    Female Male    Female
Date of Birth
Nicotine User Yes    No Yes   No
Face Amount $,000  $,000
Policy Type
Waiver of Premium Yes     No Yes    No

 

 

CONTACT  INFORMATION

Preferred Method of Contact
 
E-mail
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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