1st State Agency of Sauk Centre, Minnesota, will contact you by phone within 3 business days.

*Last
*First
*Middle
*Address
*City
*State
*Zip
*Home Phone
Work Phone
Fax
Email
Date of Birth
Credit
Occupation
Years @ present job

Structure Information
Miles from FD
Any acerage
Type of heat:
In floor radiant heating?
Yes
No
If yes, %
Woodstove
Yes
No
Type of flue
Fireplace
Chimney Yes
No
Year Built
Wiring Updated?
year
Plumbing Updated? year
Roof Updated?
year
Heating Updated? year
Home Dimensions (without garage)
What type of garage?
Detached Structures (dimensions)
Deck (sq feet)
Type of Siding
Central Air Yes
No
Hot Tub Yes
No
# Of Bathrooms
Cathedral Ceilings

If yes, %

Recessed Lighting If yes, %
Wall Covering
Ceilings
Windows
Doors
Flooring % Oak
% Laminate
% Carpet
% Tile
% Vinyl
% Other
Basement

Home Style

Rambler
Yes
Bi-Level
Yes
Tri-Level
Yes
Basement
Basement Finished
Yes
No
Basement Finished
If yes, %
Balcony (sq feet)
Breezeway (sq feet)
Patio

Previous Coverage

Current Insurance Provider
Policy #
Expiration Date
Current Deductible
Dwelling Value

Other Structures
Personal Property
Liability
Medical Pay
Loss of Use
Replacement Cost On Personal Property Yes
No
Guaranteed Replacement Cost on Home Yes
No

Mortagee

Loan #

Any Additional Property/Liability Risks

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.

By filling out this quote you agree to the above.