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E-Mail:
info@insuring
minnesota.com

Phone Lines:
1-800-972-4292
ext. 425
1-952-469-0425

Fax:
1-952-469-1881

Mailing Address:
20960 Holyoke Ave
PO Box 1177
Lakeville, MN
55044

MN Insurance
License #:

44761

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On-Line Workers
Compensation Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal / Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State: (Must be Minnesota)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):
 


Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 


 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Payroll Class #1:
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
 
Send my quotation via: E-Mail Fax
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