Gerry Smith Insurance Agency
The Gerry Smith Insurance Agency
  
 
 
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  Gerry Smith Ins Agency
1020 E 146th St, Ste 107
Burnsville, MN 55337-6756

Ph  (952) 432-7310
Fax (952) 432-2204
gsmith@gerrysmithagency.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)

Gender:

 Male     Female
Married or Single: Married  Single
Is Spouse to be covered? Yes  No
Spouse's 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
Your Minnesota Residence: Twin Cities 7 County Metro Area
Out-State     If Out-State, 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 Coverage 1  2  3  4  5
Having The Cheapest Coverage 1  2  3  4  5
Length of Time Coverage is Needed: 0-3 Months   3-12 Months   Over 1 Year 
 
 

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.

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