Group Disability Insurance Quote Minnesota

**Information received from this Group Disability Insurance quote request form
sent to the Baecker Insurance Agency will be for our use only and will not be
sold, given to or distributed to any other parties. A quote will be based on the
group disability insurance policy information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of
the policy as issued. By submitting this request you acknowledge that this is
neither an offer to insure nor a guarantee of insurance. Completion of this form
does not entitle your business to a Minnesota Group Disability Insurance
Policy. We are licensed in Minnesota and Wisconsin and will not provide
group disability insurance quotes for other states.

We are your local St. Paul, MN insurance agency, offering experienced
Minnesota Group Employee Disability Insurance quotes to businesses in
the following Twin Cities area towns and counties: Minneapolis,
Bloomington, Roseville, Maplewood, North St. Paul, Oakdale,
Woodbury, Cottage Grove, South St. Paul, Inver Grove Heights, Eagan,
West St. Paul, Richfield, Burnsville, Edina, Lilydale, Mendota Heights,
St. Paul Park, Lake Elmo, Newport, Cedar Grove, Savage, Shakopee,
Eden Prairie, Minnetonka, Hopkins, St. Louis Park, Plymouth, Golden
Valley, Columbia Heights, New Hope, Crystal, Robbinsdale, Brooklyn
Center, Fridley, New Brighton, Maple Grove, St. Anthony, Arfen Hills,
Shoreview, Vadnais Heights, Little Canada, White Bear Lake,
Mahtomedi, Grant, Bellaire, North Oaks, Gem Lake, Mounds View,
Lino Lakes, Blaine, Coon Rapids, Spring Lake Park, Lexington, Afton,
Lakeland, Bayport, Stillwater, Apple Valley, Andover, St. Cloud,
Mankato, Rochester, Duluth, Anoka, Champlin, Andover, Oak Grove,
St. Michael, Hanover, Scandia, Forest Lake, Wyoming, Rosemount,
Hastings, Vermillon, Coates, Ramsey County, Hennepin County, Dakota
County, Anoka County, and Washington County, MN. We also offer
business insurance services in the remainder of Minnesota and
throughout Wisconsin.

Business Name:
Premises Address:
City:
State: (Minnesota or Wisconsin)     Zip Code:
Contact Name:
Phone #:    Ext #:    Years in Business:
Email Address: (Required)
Description of Operations or SIC code:

Current Insurance Company:
Policy Expiration Date:          (mm/dd/yyyy)

Do you currently offer short term disability insurance to employees?
Do you currently offer long term disability insurance to employees?
Length of Group Disability Coverage Needed?

Group Disability Coverage For?
Type of Group Disability Coverage Needed?
How many employees to be insured?

Monthly Benefit Amount For Each Person Insured:
Or Enter a Different Monthly Benefit Amount:         $
Benefit Period Desired For Each Person Insured:
Elimination Period Desired For Each Person Insured:
Payment Mode:

Does any employee to be insured have a hazardous job? Yes No
If Yes, how many have hazardous jobs?

Are any employees to be insured active members of the military reserves? Yes No
If Yes, how many are active members of the military reserves?

Explain any recent Minnesota workers comp claims below:

Additional Information or Comments

Click on the "Submit Quote Information" button below to send
your Minnesota Group Disability insurance quote request.**