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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


Minnesota Health Insurance Quote Inquiry Form
This inquiry form will allow us to provide you with a health 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.


First Name   MI  
Last Name
Zip Code



Date of Birth:



Male     Female
Married or Single: Married  Single
Is Spouse to be covered? Yes  No
Spouse's Date of Birth: (mm/dd/yy)
Children to be covered? Yes  No
Number of Children: 0 1 2 3 4 5
Self-employed? Yes  No
Your Current Health Provider:
Your Current Health Plan: Employer Sponsored  Individual
Under COBRA  None
Your Minnesota Residence: Twin Cities 7 County Metro Area
Out-State     If Out-State, Specify County:


 Please provide the following information so that we may provide you information on a plan that most closely fits your needs. Choose one answer for each. 5 = "very important" , and a 1 = "not important".

Choice of Doctor 1  2  3  4  5
Preventative Care Coverage 1  2  3  4  5
Pregnancy Coverage 1  2  3  4  5
Prescription Drug Card 1  2  3  4  5
Chiropractic Coverage 1  2  3  4  5
Eye Exam Coverage 1  2  3  4  5
Having The Best Coverage 1  2  3  4  5
Having The Cheapest Coverage 1  2  3  4  5
Length of Time Coverage is Needed: 0-3 Months   3-12 Months   Over 1 Year 

Do any applicants have any pre-existing health conditions? (If yes, comment below)





Preferred Method of Contact
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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