Perrine Agency - Minnesota Independent Insurance Agent in MN

Business Owners Insurance Quote Request

To receive a free 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 *Required

Company Name

Your First Name*

Last Name*

Street Address

City

State

Zip Code

Phone - include area code and extension*

Fax - include area code

Email Address*

FEIN or SS # if individual*

Website

Type of Business: Sole Proprietor Corporation Partnership
LLC Association

Yes No - Do You Currently Have Business Owners Insurance?

If yes, who is your current insurance company?

If yes, when does your current policy expire?

Describe your business operations:

Year Business Established:

Years at Current Location:

Check the following that applies to your office space:
Own Lease Neither

Number of Locations:
Number of Employees:
Annual Gross Revenue:	$ (approx.)
Company Payroll (Total):	$ (approx.)
Amount of Insurance Desired:	$
Office Space Square Footage:	(approx.)
Entire Building Square Ftge:	(approx.)

Have you been named in a lawsuit in the past 2 years?

Yes No

If yes, briefly explain:

OPTIONAL COVERAGES

Check any additional policies you may be interested in:

Group Health	Business Property	Malpractice
Workers Comp	Errors/ Omissions	Commercial Auto/ Truck
Other	Business Liability

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

Enter any comments/ questions/ suggestions below:

Click below to submit information.