Theis Insurance Agency

PO Box 111
St Michael, MN 55376
(763) 497-5133 phone

Home Insurance Quote Request Page

The minimum requirements to receive your free home insurance quote is to want to insure a house within 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 all 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:

Current Insurance Information

Policy Type Desired? Homeowners Landlords Condominium Townhouse Renters
Current insurance carrier (If you do not have a current insurance carrier type in NONE)
Policy Expiration Date/Premium Due Date
Amount of Insurance Desired
Dwelling Coverage (Amount of Insurance)
Separate Structures
Personal Property/Contents
Medical Payments
Personal Liability (Bodily Injury and/or Property Damage)
Personal Injury Liability (Slander,Discrimination,False Arrest,ect.)
Deductible
Number of Claims Filed Within the Past 5 Years Please explain loss details, in the comments section below.

Additional Information/Comments

If you need any special endorsements (jewelry, guns, collectibles, furs, fine arts, etc.) or to clarify any items above: Please explain here.

Building Information

Year Built
Number of Stories.
Total Square Feet
Total Finished Square Feet
Construction Type (Ranch, 2 story, Split entry, Tri-level, ect.)
What Type of Roof do you have? (asphalt shingles, wood shakes, tar and gravel, tile, slate, ect.)
What is the Age of the Roof?
Garage Type/Size
Number of Bathrooms
Number of Fireplaces
Does your home have a Deck?	Yes No
Do you have Monitored Central Burglar Alarm?	Yes No
Does your house have, Central Heating and Air Conditioning?	Yes No
Do you have a Swimming Pool?	Yes No
Is Flood Insurance Desired?	Yes No
Is Earthquake Insurance Desired?	Yes No
If you have any other special features in your home, please explain in the comments section above.

Your request for a quote or the form

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