Minnesota Auto Insurance Quote

**Information received from this Minnesota Auto 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 auto
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 you to a
Minnesota Auto Insurance policy. We are licensed in Minnesota and Wisconsin
and will not provide quotes for other states.

We are your local St. Paul, Minnesota insurance agency, offering
affordable Auto, Car, and Truck Insurance policy premiums 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
auto insurance services in the remainder of Minnesota and throughout
Wisconsin.

Full Name:
Mailing Address:
City:
State: (Minnesota or Wisconsin)     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Current Insurance Company:
Expiration Date: (mm/dd/yyyy)

Vehicle     Year             Make                Model                Body Type
     1
     2
     3

Pickup Truck Information (if applicable):
Does your truck have a cap?
If Yes, what is its value: $
Does your truck have a snow plow?
If Yes, what is its value: $

Vehicle     Primary Use     Miles Driven to Work
     1
     2
     3

                                                           Where          Lienholder        Lienholder
Vehicle              VIN#                      Garaged          Yes/No               Name                Who Titled To
     1
     2
     3

                      Liability                 Property                   Uninsured
Vehicle    Limits(x $1,000)          Damage             Motorist(x $1,000)       Medical
     1
     2             SAME                       SAME                       SAME                   SAME
     3             SAME                       SAME                       SAME                   SAME

                   Collision         Comprehensive
Vehicle    Deductible           Deductible
     1
     2
     3

Endorsements
Vehicle      Towing                   Rental
     1
     2
     3

                                  Drivers                     Date of                                         Drivers
Driver                       Name                          Birth                  Gender            License #              State
     1
     2
     3

                                  Drivers                  How Long          Social                     Marital
Driver                    Occupation                Licensed         Security #                 Status
     1
     2
     3

Is your driving record accident & violation free during the past 5 years?
Driver
     1       If No, how many accidents?    How many violations?
     2       If No, how many accidents?    How many violations?
     3       If No, how many accidents?    How many violations?

Was your driver's license suspended during the past 5 years?
Driver
     1
     2
     3

Additional Information or Comments

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