Theis Insurance Agency

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

Life Insurance Quote Request Page

The minimum requirements to receive your free life insurance quote is to live 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

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:

Insurance Policy Information

Policy Type Desired? Term Whole Life Universal Life Other
Death Benefit (Amount of Insurance)
Gender Male Female
Do you use any nicotine? Yes No
Do you want a waiver of premium? Yes No
Do you have any known health problems? Yes No   If so, please explain below

Additional Information/Comments

If you need to clarify any items above: Please explain here.

Your request for a quote or the form.

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