MN Group Life Insurance Quote

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

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

Group Term Life Insurance Objective:
Amount of Life Insurance Desired Per Employee:    Other Amount:$

How many employees to be insured:

Did any employee to be insured have health problems during
the past 18 months?
If "Yes", please list information below.

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?

Additional Information or Comments

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

We are your local St. Paul, Minnesota insurance agency, offering
experienced Group Life Insurance services 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.

**Information received from this Group Life 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 life 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 Life Insurance Policy. We are licensed in Minnesota and
Wisconsin and will not provide group life insurance quotes for other states.