Theis Insurance Agency

PO Box 111
St Michael, MN 55376
(763) 497-8140 phone




Auto Insurance Quote Request Page

The minimum requirements to receive your free auto insurance quote is to be a resident of Minnesota and complete all items marked with a *.

The more information you supply, the more accurate the quote. All quotes are subject to verification of driving records and other underwriting factors.

Basic Address Information

Name*
Address*
City* Zip Code*    

Please supply either a Daytime or Evening Phone Number
Also the best time to call.*
Home Phone Number:  
Work Phone Number:  
Best Time To Call Morning Afternoon Evening  
E-mail Address:

Do you currently own your own home?
Yes No
 
Current insurance carrier*
(If you do not have a current insurance carrier type in NONE)
Current Policy Number
How long have you been continuously insured?   years
Policy Expiration Date/Premium Due Date



Driver Information

Driver #1 Driver #2 Driver #3 Driver #4
Name*
License
Sex* Male
Female
Male
Female
Male
Female
Male
Female
Date of Birth*
Social Security Number
Tickets in last 3 years* Please explain in comments below Please explain in comments below Please explain in comments below Please explain in comments below
Accidents in last 3 years* Please explain in comments below Please explain in comments below Please explain in comments below Please explain in comments below
Good Student Discount GPA GPA GPA GPA
Daily Commute* miles one way miles one way miles one way miles one way





Vehicle Information

Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Year*
Make*
Specific Model*
Passive Restraints Driver Side Airbag
Dual Airbags
Driver Side Airbag
Dual Airbags
Driver Side Airbag
Dual Airbags
Driver Side Airbag
Dual Airbags
Used for Business? Yes
No
Yes
No
Yes
No
Yes
No
Total Annual Miles
VIN#





Coverages Desired

Limit of Bodily Injury Liability
Limit of Property Damage Liability
Uninsured Motorist
Under Insured Motorist
Comprehensive Deductible
Collision Deductible
Towing Emergency Road Service Yes
No
Yes
No
Yes
No
Yes
No
Loss of Use Yes
No
Yes
No
Yes
No
Yes
No





Additional Information/Comments

If you have any tickets or accidents please explain here

If you have any questions, please call my office at: 763-497-5133 and I will gladly answer your questions. I look forward to helping you.

Your request for a quote or the form


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