1st State Agency of
Sauk Centre, Minnesota, will contact you by phone within 3 business days.
Be prepared with your vin number.
|
*Business
Name
|
|
| *Mailing
Address |
|
| *City |
|
| *State |
|
| *Zip |
|
| *Home
Phone |
|
| *Business
Phone |
|
Website |
|
| Fax |
|
| Email |
|
Date
Business Started |
|
| Number
of Employees |
|
Inspection
Contact |
|
Accounting
Contact |
|
FEIN
(if available) |
Mailing Address if different from above
| Business
Location Address |
|
| City |
|
| State |
|
| Zip |
Premises Information
| Location 1 | Address |
|
| City
Limits |
||
| Owner |
||
| Year
Built |
||
| Construction |
||
| Part
Occupied |
||
| Location 2 | Address |
|
| City
Limits |
||
| Owner |
||
| Year
Built |
||
| Construction |
||
| Part
Occupied |
||
|
|
||
| Driver | First
Name |
|
| Last
Name |
||
| Gender |
Male Female |
|
| Marital
Status |
||
| State
Licensed |
||
| Driver's
License Number |
||
| Occupation |
||
| Date
of Birth |
||
Good
Student |
||
| Driver 2 | First
Name |
|
| Last
Name |
||
| Gender |
Male Female |
|
| Marital
Status |
||
| State
Licensed |
||
| Driver's
License Number |
||
| Occupation |
||
| Date
of Birth |
||
Good
Student |
||
Nature
of Business/ Description of Operation by Premise(s)
Remarks/Comments
| Many insurance agencies use information gathered from you and outside sources about your claim, driving or credit history. This information helps insurance companies determine the proper quote. Comanies that
claim to get you a quote in 15 minutes or less, are placing speed
over accuracy and personal attention is no longer part of the equation.
First State Agency will not push you towards something you don't
want or need, we will guide you. |