Minnesota Life Insurance Quote

**Information received from this 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 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 you to a Life
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
Term, Universal, and Whole Life 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 life 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:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have life insurance?
Type of life insurance currently owned:
Current Premium:$ per month

Who will be insured:
Type of life insurance desired:
Amount of Life Insurance Desired:    Other Amount:$
Benefit Period Desired:

Has anyone to be insured had health problems during the past 2 years
or been diagnosed with a serious illness?
If "Yes", please list information below.

Does anyone to be insured have a hazardous job? Yes No
Is anyone to be insured an active member of the military reserves? Yes No

Additional Information or Comments

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