The Gerry Smith Insurance Agency
  
 
 
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  Gerry Smith Insurance Agency
151 W Burnsville Pkwy
Suite 240
Burnsville, MN 55337-2557

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

Soc Sec #

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