Get FREE Tips on How to Lower Your Insurance Premiums


(enter email address)

  
 


click here to receive
a quote and/or
apply online for
Medica Health
Insurance

  
     


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.

 

 
 


"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