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  Knutson Insurance Agency
12280 Nicollet Ave Ste104
Burnsville,  MN   55337

Ph (952) 224-0110

Fax (952) 224-0400



Minnesota Health Insurance Quote Request
This request form will provide you with an health insurance cost and coverage summary based on the information you provide below. This is not an application for insurance. We recommend that you have a current copy of your insurance policy to refer to as you complete this form. After you have completed this form, click the Submit button at the bottom of the page.


First Name   MI  
Last Name
Zip Code



Date of Birth:

-- mm/dd/yy


Male Female
Married or Single: Married Single
Spouse to be covered ... ? Yes No
Spouse; Date of Birth: -- mm/dd/yy
Children to be covered? Yes No
Number of children: 0 1 2 3 4 5
Self-employed? Yes No
Your current health provider?
Your current health plan? Employer Sponsored Individual
Under COBRA None
Where do you Live: Twin City 7 County Area

Outstate; Specify County:


Plan Preferences:
 Please provide the following information so that we may provide you information on a plan that most closely fits your needs. Choose one answer for each. 5 = "very important" , and a 1 = "not important".

Choice of Doctor? 1 2 3 4 5
Preventative Care Coverage? 1 2 3 4 5
Pregnancy Coverage? 1 2 3 4 5
Prescription Drug Card? 1 2 3 4 5
Chiropractic Coverage? 1 2 3 4 5
Eye Exam Coverage? 1 2 3 4 5
Having the best possible coverage? 1 2 3 4 5

Having the least expensive?

1 2 3 4 5

How long will you need coverage?

0-3 Months 3-12 Months 1+ Years

Do any applicants have any pre-existing health conditions? (If yes, comment below)





Preferred Method of Contact
Phone Number
Fax Number
Postal Mailing Address
Questions or Comments

Please press the Submit button.
Wait a few moments for an online acknowledgment.


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