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Classic Car Insurance Quote Request
To receive a classic 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
 
  Married or Single?
 
  Phone (Cell) - include area code
 
  Phone (Home) - include area code
 
  Phone (Work) - include area code and extension
 
  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 classic car 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
 
 
 
  Name of Current Insurance Provider (if applic.)
 
  Vehicle Manufacturer (eg Chevy, Ford)
 
  Model (eg Corvette, Thunderbird)
 
  Year of Model
 
  Value (in U.S. dollars)
 
  Where kept and usage (miles/ year)
 
  VIN # (Vehicle Idenfitication Number)
 
  # of miles on odometer
 
 Check the following that applies:
 Vehicle contains all original parts
 Vehicle has been restored

 Additional questions:

  1.  List group membership if applicable: 

  2.  If you show your car, list how many times per year:

  3.  Describe primary car information:
 
 
  DESIRED COVERAGES
 
Check type of policy you would like:
Liability Full Coverage Not sure
 
30/60/10-25 50/100/25-50 100/300/50-100
  
Yes   No   -   Include additional drivers in quote?
 
 If yes, how many additional drivers?  
 
  ADDITIONAL VEHICLE INFORMATION
  
Include Additional Vehicles in Quote?  Yes   No
 
Additional Vehicle 1 Make, Model, Year and VIN:
 
 
Additional Vehicle 2 Make, Model, Year and VIN:
    
 
Additional Vehicle 3 Make, Model, Year and VIN:
 

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

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