Perrine Agency - Minnesota Independent Insurance Agent in MN

Term Life Insurance Quote Request

To receive a free term life 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 (Work) - include area code and extension

Phone (Home) - include area code

Email Address

Date of Birth (month/ day/ year)

Height

Weight

Gender: Male Female

Yes No - Do You Currently Have Term Life Insurance?

If yes, who is your current insurance company?

Yes No - Are You, Your Dependents, or Spouse Pregnant?

Yes No - Do you have any pre-existing medical conditions?

If yes, list here:

Yes No - Do you currently take any prescription medications?

If yes, list here:

Yes No - Do you use tobacco products?

- Length (in years) of desired policy

Choose Amount of Insurance Coverage:
$ Not sure, would like to discuss

SPOUSE INFORMATION

Include Spouse in Quote? Yes No

Spouse Gender: Male Female

Full Name (First, Middle, Last)

Spouse Height (ft, inches)

Spouse Weight (lbs.)

Spouse Date of Birth (month/ day/ year)

Yes No - Does your spouse use tobacco products?

OPTIONAL COVERAGES

Check any additional policies you may be interested in:

Disability	Life Insurance	Long Term Care
Hospital	Prescription Card	Maternity
Senior Care	Supplemental Accident

CHILDREN

Include Children in Quote? Yes No

Child 1: Name Date of Birth (Month/ Day/ Yr)

Child 2: Name Date of Birth (Month/ Day/ Yr)

Child 3: Name Date of Birth (Month/ Day/ Yr)

Child 4: Name Date of Birth (Month/ Day/ Yr)

When do you need your coverage?
Immediately
1 to 3 months from now
Just checking price

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

Enter any comments/ questions/ suggestions below:

Click below to submit information.