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Prescription Drug Savings Plans Quote Request
To receive a free prescription drug savings plan 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 Rx Drug Savings Plan?

 If yes, who is your current 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?
Choose Preferred Deductible Amount:

 $250    $500  $1000  $2500  $5000
 
 
  OPTIONAL COVERAGES
 
Check any additional policies you may be interested in:
 
Disability Life Insurance Long Term Care
Hospital Supplemental Accident Maternity
Senior Care    
 

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