David Mugg Agency | St. Michael, MN
Thank you for the opportunity to earn your business! Filling out this form speeds up the quoting process for you and for us. Thank you for your help! -DAVID MUGG & STAFF
Contact
Name
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First Name
Last Name
Date of Birth
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Month
/
Day
Year
Gender on Driver's License
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(M) Male
(F) Female
(X) Non-binary / Third gender
Email Address
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A copy of this form will be emailed to you for your records.
Telephone Number
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Format: (000) 000-0000.
Phone Type
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Mobile (Cell Phone)
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Check this box if you're cool with us texting you prices or quick questions to speed things up.
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Residence Address
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Address
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Check here if you have a seperate mailing address from your residence address or a PO Box.
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Marital Status
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Single or Separated
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Let's see if we can make your life easier. What has you shopping for Insurance?
*
Lower Price
Better Coverage
Local Agent
Better Agent
Checking/curiosity
Renewing soon
Other
Back
Next: Household
Household
Let's make sure all drivers are covered!
Number of Drivers
*
Please Select
1 (Just me)
2
3
4
5+
Include all drivers who are licensed or have a learner's permit. If you're married, please include your spouse's information as Driver 2 even if they don't drive.
Spouse or Driver 2
Spouse or Driver 2
First Name
Last Name
Relationship to you
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Spouse / Partner
Child
Parent
Roommate
Other
Gender
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(M) Male
(F) Female
(X) Non-binary / Third gender
Date of Birth
/
Month
/
Day
Year
Date
Good Student Discount
Please Select
Yes
No
Young Drivers ages 16-25 who are enrolled as full-time students and have had a 3.0 GPA or higher in the past 12-months qualify for this discount.
Driver 3
Name
First Name
Last Name
Relationship to you
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Spouse / Partner
Child
Parent
Roommate
Other
Gender
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Male
Female
Non-binary / Third gender
Date of Birth
/
Month
/
Day
Year
Date
Good Student Discount
Please Select
Yes
No
Young Drivers ages 16-25 who are enrolled as full-time students and have had a 3.0 GPA or higher in the past 12-months qualify for this discount.
Driver 4
Name
First Name
Last Name
Relationship to you
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Spouse / Partner
Child
Parent
Roommate
Other
Gender
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Male
Female
Non-binary / Third gender
Date of Birth
/
Month
/
Day
Year
Date
Good Student Discount
Please Select
Yes
No
Young Drivers ages 16-25 who are enrolled as full-time students and have had a 3.0 GPA or higher in the past 12-months qualify for this discount.
Driver 5
Name
First Name
Last Name
Relationship to you
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Spouse / Partner
Child
Parent
Roommate
Other
Gender
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Male
Female
Non-binary / Third gender
Prefer not to say
Date of Birth
/
Month
/
Day
Year
Date
Good Student Discount
Please Select
Yes
No
Young Drivers ages 16-25 who are enrolled as full-time students and have had a 3.0 GPA or higher in the past 12-months qualify for this discount.
I need to include more drivers
Yes
No (5 Drivers Only)
Back
Next: Vehicles
Vehicles
How many vehicles do you have?
*
Please Select
1
2
3
4
5
6 or more
I don't own a vehicle
Vehicle 1 Details
Year:
Make
Model
Vehicle 2 Details
Year:
Make
Model
Vehicle 3 Details
Year:
Make
Model
Vehicle 4 Details
Year:
Make
Model
Vehicle 5 Details
Year:
Make
Model
Back
Next: Discounts
Discounts
Let's maximize your savings!
Are you currently insured?
*
Please Select
Yes, I have my own policy or I am listed as a driver on a policy.
No, my last insurance policy is no longer active or in force.
Choose the answer that best applies to your situation.
How long have you continuously had Auto insurance?
*
Less than a year
1 to 2 years
2 to 3 years
4+ years
Current* Auto Insurance Company
*
Please Select
AAA
AIG
Allstate
American Family
American Financial
Amica
Auto Owners
Bristol West
Chubb
Cincinnati
Country Financial
Encompass
Esurance
Foremost
Geico
Grinnell
Hagerty
Hanover
JC Taylor
Liberty Mutual
Mercury
MetLife
Nationwide
Progressive
Safeco
State Farm
The General
The Hartford
Travelers
USAA
Zurich
Never Previously Insured
Other
*Or the last company you had a policy with.
How much are they charging you?
(TOTALLY OPTIONAL!) Let’s be real—price matters! We’ll email you your quote and price options, then leave you alone if Farmers isn’t cheaper. No pressure, no sales games—just transparency. That way, we can focus on helping folks who can save.
Veteran Discount
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Yes
No
Special Discounts for Veterans, Active and Reserve Service Members.
THANK YOU FOR YOUR SERVICE!
You deserve a discount!
I'm a Business Owner
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Yes
No
While we're at it, we can check any commercial policies while you have insurance on your mind..
Own or Rent your home?
*
Please Select
Rent
Own
SAVE MORE! Bundling is our biggest discount. While we run your Auto quote, we’ll quickly check your bundle price too—just to see if we can save you even more. Typically, if we’re saving you on Auto, there’s a good chance we can save you on Homeowners, too!
Home's Shingle Year
*
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2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2010
2009
2008
2007
2006
2005 or older
Renter, Apartment, Townhome or Condo Owner
For Homeowners policies only. It's okay if you're not sure right now. Take your best guess.
Current Home/Renter/Condo/Townhome Insurance Company
*
Please Select
I bundle! (Same as Auto Ins.)
I don't have/need Home/Renter/Condo/Townhome Insurance
AAA
American Family
Progressive
State Farm
Nationwide
Geico
Travelers
Liberty Mutual/Safeco
USAA
Allstate
Country Financial
Auto Owners
The General
Esurance
Encompass
The Hartford
Chubb
Grinnell
Cincinnati
Hagerty
JC Taylor
Bristol West
Mercury
Foremost
Hanover
Amica
American Financial
AIG
Zurich
MetLife
All Others
Dwelling, Home, Condo, Renters, Townhome, etc.
Yearly Home Premium?
Most homeowners have this payment set up through their escrow account with their mortgage. For easiest price comparing, check your annual premium amount on your Homeowners insurance documents.
Is there anything else we should know to more accurately quote you?
Any areas of concern you would like to let us know right away? e.g. "I have a [Boat/Motorcycle/Classic Car/RV/Trailer/Life Insurance or some other kind of] policy to check, also." or "My child is getting their learner's permit soon," etc.
SUBMIT
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