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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 Townhome/Condo Insurance Quote Inquiry Form
This inquiry form will allow us to provide you with a townhome/condo  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
Date of Birth  
Spouse's Date of Birth (if applicable)    

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

 

PROPERTY  COVERAGES

Personal Property $         Contents Replacement Cost
Building Property $
Loss of Use
Loss Assessment $
Personal Liability $
Guest Medical $
Back-Up Sewer & Drain $  
Additional Coverage 1)           Amount  $
Additional Coverage 2)            Amount  $
Additional Coverage 3)            Amount  $
Child Care on Premises
Deductible $
Current Insurance Company

 

GENERAL INFORMATION

Year Built          Market Value  $
Non- Smoker Yes   No
Protective Devices 1)
Protective Devices 2)

Claims (Last 3 Years)

Date (mo/yr)                 Description

Claim #1

    

Claim #2

    

Claim #3

    

 

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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