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Auto Insurance / Car Insurance Quote Request
To receive a free auto / car insurance quote from the Perrine Agency, answer the following questions and submit.  An agent will analyze your information and contact you shortly.  You may also print out this page, fill in at your convenience, and fax to us at (952) 888-1134.

 YOUR INFORMATION
 
  First Name
 
  Middle Name
 
  Last Name
 
  Street Address
 
  City
 
  State
 
  Zip Code
 
  Phone (Cell or Work) - incl. area code and ext.
 
  Phone (Home) - include area code
 
  Email Address
 
  Date of Birth (month/ day/ year)
 
  Your Drivers License Number
 
  State of Your Current License
 
 VEHICLE INFORMATION / QUESTIONS
 
Yes   No  - Do you currently have auto insurance?

 If yes, with who, date or next renewal and why are you changing?
 

 If no, why do you currently not have insurance?
 
 
Yes   No  - Have you had any accidents, violations or tickets?

  If yes, describe any accidents/ violations or tickets:
  3 year history required - regardless of fault.
 
 
 
  (if applic.) Name of Current Insurance Provider
 
  Year of Model
 
  Vehicle Manufacturer (eg Toyota, Chevrolet)
 
  Vehicle Model (eg Taurus, Camry)
   
  VIN # (Vehicle Idenfitication Number)
 
 Check the following that apply:

 Airbag equipped   Antilock brakes   Security alarm
 
  DESIRED COVERAGES
 
Check type of policy you would like:
Liability only. Full Coverage Not sure
Full glass Towing Rental car coverage
 
 Coverage limits - if unsure, contact us for clarification.
30/60/10-25 50/100/25-50 100/300/50-100
  
Yes   No   -   Include additional drivers in quote?
 
 Number of additional drivers in household?   if yes, list below
 
  Additional Driver #1 - Name, Birthdate, Drivers Lic #, Relation:
 
 
  Additional Driver #1 - Name, Birthdate, Drivers Lic #, Relation:
    
 
  Additional Driver #1 - Name, Birthdate, Drivers Lic #, Relation:
 
 
  ADDITIONAL VEHICLE INFORMATION
  
Include Additional Vehicles in Quote?  Yes   No
 
Additional Vehicle 1 Year, Make, Model and VIN:
 
 
Additional Vehicle 2 Year, Make, Model and VIN:
    
 
Additional Vehicle 3 Year, Make, Model and VIN:
 

What is the best time of day to reach you by phone? 

What is the best way to reach you? (cell, home, email, fax?)


Enter any comments/ questions/ suggestions below:

Click below to submit information.

 

 
 


"Don was able to find us the best package to meet our needs at the best price and provided friendly, personal service.  Glad we found you!"

Kevin & Jill Unterreiner
Eden Prairie, MN