Home
  Auto Quote
  Motorcycle Quote
  Boat Quote
  Personal Watercraft
  Snowmobile Quote
  Home Owners Quote
  Townhome Quote
  Renters Quote
  Life Quote
  Umbrella Quote
  Health Quote
  About Us
  Contact Us
 
 
 
  Knutson Insurance Agency
12280 Nicollet Ave Ste104
Burnsville,  MN   55337

Ph (952) 224-0110

Fax (952) 224-0400

info@knutsonagency.com

 

 
 
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.
 

PERSONAL  INFORMATION

First Name   MI  
Last Name
Address
City
State
Zip Code

 

GENERAL INFORMATION

Date of Birth:

-- mm/dd/yy

Sex:

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
Occupation?
Your current health provider?
Your current health plan? Employer Sponsored Individual
Under COBRA None
Where do you Live: Twin City 7 County Area
Outstate

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)

 

 
 

 

CONTACT  INFORMATION

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

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

 

2006  Knutson Insurance Agency - All Rights Reserved