Midland Insurance Group

auto Auto Insurance Quote Fax Form

Please print this form, fill in the information, and fax it to
(320) 485-2199

Also, fax us a copy of your current Auto Coverage Policy Page.
This will give us the information regarding vehicles and type of coverage you currently have.

Name

 _______________________________________________________

Phone number
with area code

 _______________________________________________________

Best time to call

 _______________________________________________________

Driver Name

Date of Birth

Driver License No.

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________
 List any accident any named driver has had in the last 5 years, along with the approximate date and dollar amount of damage for each.
Thank You!
We will contact you soon!
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