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952-479-5877

2431 Galpin Ct #140
Chanhassen, Minnesota 55317

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Active Insurance Solutions

Personal Information

Full Name ✶

Email ✶

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Policies to be Shopped/Quoted (Select all that apply) ✶

Auto

Existing Home

New Purchase Home

Renters

Auto Insurance

Are there any changes to the vehicles or coverages you are requesting relative to what you have on your existing policy today?

Yes No

Please provide details.

Are there youthful drivers currently in the household?

Yes No

Any changes in Good Grade discount or eligibility for Youthful Drivers in the Household?

Yes No

Are any of the youthful drivers at school (more than 100 miles away) without a vehicle during the school year?

Yes No

Please provide details.

Any upcoming changes for Youthful Drivers in the household?

Yes No

Are you anticipating adding any youthful drivers within the coming 12 months?

Yes No

Does anyone in the household currently drive for Uber/Lyft or do Food Delivery?

Yes No

Please provide details.

Any other comments, questions, or relevant information we should have as we look to secure new quotes for you?

Home Insurance

Confirm Property Address

Any renovations completed since we wrote your current policy for you (additions, finishing basement, adding bathrooms, etc.).

Yes No

Please provide details.

Any businesses conducted out of your home (in-home day care, beauty salon, etc.)?

Yes No

Please provide details.

Dogs in Household?

Yes No

What breed?

Wood Burning Stove?

Yes No

Trampoline?

Yes No

Fence in Backyard?

Yes No

Netted?

Yes No

Pool on Premises?

Yes No

Diving board?

Yes No

Fenced?

Yes No

Central Burglary Alarm System?

Yes No

Central Fire Alarm System?

Yes No

Any updates to the roof since we wrote your most recent policy for you?

Yes No

Year Replaced

Any updates to the furnace since we wrote your most recent policy for you?

Yes No

Year Replaced

Any updates to the plumbing since we wrote your most recent policy for you?

Yes No

Year Replaced

Any updates to the electrical since we wrote your most recent policy for you?

Yes No

Year Replaced

Any valuables recently acquired that you are interested in scheduling for more comprehensive protection (jewelry, fine arts, firearms, etc.)?

Yes No

Please provide details

Do you currently have an Umbrella policy with us?

Yes No

If not, are you interested in receiving a quote?

Yes No

Do you have separate life insurance policies in place outside of any that is included/provided through your employer?

Yes No

Are you interested in receiving life insurance quotes?

Yes No

Any other comments, questions, or relevant information we should have as we look to secure new quotes for you?

New Home Insurance

Confirm New Purchase Address

Estimated Closing Date

What are your plans for the prior residence? (Selling Home, Moving Out, Converting to Rental Property, Secondary Home, etc.)?

Will any businesses be conducted out of your new home (in-home day care, beauty salon, etc.)?

Yes No

Dogs in Household?

Yes No

What breed?

Wood Burning Stove?

Yes No

Trampoline?

Yes No

Pool on Premises?

Yes No

Central Burglary Alarm System?

Yes No

Central Fire Alarm System?

Yes No

Do you know the year of last replacement for the roof on the new home?

Yes No

Year Replaced

Do you know the year of last replacement for the heating on the new home?

Yes No

Year Replaced

Do you know the year of last replacement for the electrical on the new home?

Yes No

Year Replaced

Do you know the year of last replacement for the plumbing on the new home?

Yes No

Year Replaced

Any valuables recently acquired that you are interested in scheduling for more comprehensive protection (jewelry, fine arts, firearms, etc.)?

Yes No

Please provide details

Do you currently have an Umbrella policy with us?

Yes No

If not, are you interested in receiving a quote?

Yes No

Do you have separate life insurance policies in place outside of any that is included/provided through your employer?

Yes No

Are you interested in receiving life insurance quotes?

Yes No

Any other comments, questions, or relevant information we should have as we look to secure new quotes for you?

Renters Insurance

Confirm Property Address

Any businesses conducted out of your apartment/condo (in-home day care, beauty salon, etc.)?

Yes No

Dogs in Household?

Yes No

What breed?

Any valuables recently acquired that you are interested in scheduling for more comprehensive protection (jewelry, fine arts, firearms, etc.)?

Yes No

Please provide details

Do you currently have an Umbrella policy with us?

Yes No

If not, are you interested in receiving a quote?

Yes No

Who manages your life insurance policies outside of your employer?

If you do not have life insurance currently, are you interested in receiving some quotes?

Yes No

Any other comments, questions, or relevant information we should have as we look to secure new quotes for you?

Binding Agreement

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Active Insurance Solutions ✶

Yes, it is ok Active Insurance Solutions to use text messages to communicate with me as outlined in our agency text message rules and regulations. ✶

Yes

No

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About Us

Active Insurance Solutions is an independent insurance agency located in Chanhassen, Minnesota.

Give us a call, stop by, or request a quote online to find out how much we can save you on your insurance.

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2431 Galpin Ct #140
Chanhassen, Minnesota 55317
952-479-5877
612-777-9460
office [at] aisolutionsmn [dot] com
office [at] aisolutionsmn [dot] com
Mon-Fri 9am-5pm

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