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Your Personal Data

Your Name:

Street Address:

City:

State: (Must be Minnesota)

Zip Code:

E-Mail (REQUIRED):

E-Mail again for accuracy:

Phone:

Fax (optional):

Were You Referred to an Agent?

If Yes, Whom?

Marital Status:

Homeowner?

Currently insured? (lf yes, list carrier, and # of years continuous. If none, type N/C)

DRIVER INFORMATION #1

Name:

Sex

Birthdate:

Social Security #:

Number & Type of Accidents last 3 years:

Number & Type of MINOR violations last 3 years:

Number & Type of MAJOR violations last 3 years

MN Drivers License#:

Does Driver need an SR22 FILING?

If YES to SR22 filing, why needed? (list accident/cite)

DRIVER INFORMATION #2

Name:

Sex

Birthdate:

Social Security #:

Number & Type of Accidents last 3 years:

Number & Type of MINOR violations last 3 years:

Number & Type of MAJOR violations last 3 years

MN Drivers License#:

Does Driver need an SR22 FILING?

If YES to SR22 filing, why needed? (list accident/cite)

VEHICLE #1 INFORMATION
(If “Non-Owners”, type “NON-OWNER” in “YEAR” Field)

Year of vehicle:

Make & Model:

Vehicle ID# (for rating accuracy):

Annual Mileage:

Used in business? (Explain, if yes):

VEHICLE #1 COVERAGES:

Mention Liability Limits:

Mention Comprehensive Deductible:

Mention Collision Deductible:

Uninsured Motorists Coverage?

Rental Car & Towing Coverage?

Medical and/or PIP Coverage?

VEHICLE #2 INFORMATION
(If “Non-Owners”, type “NON-OWNER” in “YEAR” Field)

Year of vehicle:

Make & Model:

Vehicle ID# (for rating accuracy):

Annual Mileage:

Used in business? (Explain, if yes):

VEHICLE #2 COVERAGES:

Mention Liability Limits:

Mention Comprehensive Deductible:

Mention Collision Deductible:

Uninsured Motorists Coverage?

Rental Car & Towing Coverage?

Medical and/or PIP Coverage?

Comments or Remarks: (List additional drivers, autos, etc, here)

If more than 2 drivers, list Additional Driver’s Names, Birthdates and driving record history here:

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