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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 Personal Liability Umbrella Insurance Quote Inquiry Form
This inquiry form will allow us to provide you with a personal liability umbrella 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)
Occupation   Spouse's Occupation (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

COVERAGES

Limit of Liability         
Number of Vehicles
Number of Drivers Under Age 21
Uninsured / Underinsured Motorist Yes No
Number of Recreational Vehicles (not including boats)
Number of Sailboats 25 to 50 feet
Number of Inboard Boats Over 50 hp    Length Feet
Number of Inboard / Outboard Boats Over 50 hp    Length Feet
Number of Outboard Boats Over 50 hp    Length Feet
Vacant Land - Number of Acres
Rental Dwellings - Number of Units
Jet Skis & Sleds
Child Care Liability - Number of Children
 

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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