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Star Insurance Agency
2682 County Road E E,
White Bear Lake, MN 55110

Phone: (651) 773 5393
Fax:      (651) 773 5898
E-mail:  hengtgen@aol.com

Carrier Affiliations
 
 
 
 
 
 

 
Call us: (651) 773 5393
Life is precious.
We just make it safer.

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General Information
First Name:*  
Last Name:  
Address:  
   
City:   State:
Zip/Postal Code:   Country:  United States
Day Phone:   Night Phone:  
Best Time To Call(HH:MM):   AM PM
E-mail Address:*  
   
Please Tell Us About The Vehicle You Drive
Vehicle 1:
Year:  
Make (Ex: Mercedes-Benz):   Model (Ex: E320 CDI):  
Style or Body Type (Ex: Sedan 4 Doors) :   VIN # (Optional):  
Yearly Mileage:  
Primary Usage:
Commute To/From Work   Pleasure  
Commute To/From School   Business Individual  
Business Corporate   Government  
Farm   Any Other  
   
Any Custom Equipment On Vehicles? (if YES, give their value & indicate which vehicle):
Where Is The Car Parked Overnight? No Cover  Garage  Carport
   
Vehicle 2:
Year:  
Make (Ex: Mercedes-Benz):   Model (Ex: E320 CDI):  
Style or Body Type (Ex: Sedan 4 Doors) :   VIN # (Optional):  
Yearly Mileage:  
Primary Usage:
Commute To/From Work   Pleasure  
Commute To/From School   Business Individual  
Business Corporate   Government  
Farm   Any Other  
   
Any Custom Equipment On Vehicles? (if YES, give their value & indicate which vehicle):
Where Is The Car Parked Overnight? No Cover  Garage  Carport
   
Coverage
 Liability or full Coverage:  
Deductible Amount:  
Current Insurance Information (if applicable)
Insurance Company Name:      
Policy Expiry Date(MM/DD/YYYY):   Term (Months):  
Same Company Policy Since? (YYYY):   Premium Amount Per Month ($):  
   
Driver's Information
Driver 1:
Full Name:   Sex:  Male Female
DL # (Optional):   Date Of Birth (MM/DD/YYYY):  
Marital Status:  Single  Married
Education:  
Occupation:  
   
Driver 2:
Full Name:   Sex:  Male Female
DL # (Optional):   Date Of Birth (MM/DD/YYYY):
 
  
Marital Status:  Single  Married
Education:  
Occupation:  
   
Accidents / Violations In Last 5 Years (Driver 1) (Driver 2)
Minor Violations - Speeding, Turn, Stop Sign, Red Light, etc.:
Accidents - Non Chargeable:
Accidents - Chargeable:
Chargeable Accident Cost ($):
Major Violations - Drunk driving, Reckless, Hit And Run, etc.:
   
Any additional comments or information that might be helpful in your quote:
   
Disclaimer
No coverage of any kind is bound or implied by submitting information via this online form.
  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.
   
Yes, I Agree.
   

 
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