location
Untitled Document
contact me
Policy Holder  
Contact Name* A value is required.
Phone
Date of Birth* A value is required.
Social Security Number* A value is required.
Email * A value is required.
Property Location
Address* A value is required.
City* A value is required.
State*
Zip* A value is required.
County* A value is required.
Current Insurance Information
Company Name* A value is required.
Current Annual Premium* A value is required.
Expiration Date* A value is required.Invalid format.
Deductible Desired*
Amount Liability*
Earthquake Coverage Desired?*
Have you filed bankruptcy within the past 7 yrs.?*
Dwelling Information
Estimated Replacement Cost A value is required.
Square Footage A value is required.
Year Contracted A value is required.
How Many Floors
 
Type of Construction
 
Other Features (check all that apply)
 
Claims
List any claims in past 3 years:
  Date of Claim Amount Paid Claim Type Description
1.
2.
3.
Personal Property
Estimated value fo your personal property
Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Art and Breakable Items
R.V./Snowmobile/Boat

* Indicates required fields

PIA
mnii
Greenbush Office
Phone: (218) 782-2141
Fax: (218) 782-2145

Roseau Office
Phone: (218) 463-3884
Fax: (218) 463-3885

Warroad Office
Phone: (218) 386-2361
Fax: (218) 386-2396
logo
trustedchoice
Toll Free: (877) 301-7101 • Office Hours: Monday - Friday 8:30 a.m. - 5 p.m. • After hours by appointment only
All information deemed reliable, but not guaranteed. All rights reserved to Agassiz Insurance©2008. www.agassizincurance.com is a secure site.
Website designed by
SandPieperDesign