Affiliated Insurance Services, LLC

Minnseota Child Care Association Members Program

Minnesota Child Care Association Members are entitled to exclusive group savings on insurance and membership. For more information, please complete the following:

Primary Information:

*First Name:

*Last Name:

*E-mail Address:

*Daytime Phone:

Evening Phone:

Marital Status:

Married

Single

Divorced

Birthdate:

Address (Street):

Address (Street 2):

City:

State:

ZIP:

Driver Information:

Note: Additional information will be collected in order to finalize quote.

Driver 1:

Name:

Relationship:

Spouse Child Dependent

Sex:

Male Female

Birthdate:

Driver 2:

Name:

Relationship:

Spouse Child Dependent

Sex:

Male Female

Birthdate:

Driver 3:

Name:

Relationship:

Spouse Child Dependent

Sex:

Male Female

Birthdate:

Auto Insurance Quote Info:

Vehicle 1:

Driver:

Purpose:

Work School Business Pleasure

Miles one-way:

Make/Model/Year:

/ /

Vehicle 2:

Driver:

Purpose:

Work School Business Pleasure

Miles one-way:

Make/Model/Year:

/ /

Vehicle 3:

Driver:

Purpose:

Work School Business Pleasure

Miles one-way:

Make/Model/Year:

/ /

*Required Fields

Affiliated Insurance Services, LLC. is Endorsed by
The Minnesota Childcare Association