Taake Insurance Auto Quote Form

Taake Insurance Agency, is licensed to sell insurance in the State of Illinios. If you are not a resident of the State, or if the exposure you wish to insure is not in the State, we will not be able to provide a quote. Quote indications provided by e-mail from this form are estimates only and are subject to change upon formal application and additional information obtained or revised. Please note that all information submitted will be held confidential except for submission to appropriate insurance carriers and/or representatives for the purpose of obtaining quotes. Taake Insurance Agency, accepts no responsibility for electronic piracy, etc., when any information is submitted electronically. Completing and submitting the following information indicates understanding and acceptance of these terms and conditions. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.
General Information
Name of Business:
Contact Name:
Street Address:
City:
   State:    ZIP: 
County:
   Email: 
Business Phone:
 ( )         
Fax:
 ( )
Best time to call:
 AM PM
Type of Business:
 Individual Corporation Partnership
Current Insurance Company (not agency)
Company Name:
Policy Exp. Date: 
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property		 Commercial Umbrella
Directors & Officers Liability
Disability
Group Health		 Group Life
Professional Liability
Workers' Compensation
Other 
About Your Business:
# of full-time employees
# of part-time employees
How long in business
How many locations
Annual Sales
yrs.
$
Please give a brief description of your business and clientel:
Vehicle Information:
(include all cars you or your business owns or leases) 
Car #1
Year
Make
Model
Sub Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Mileage
Drive to school, work, station?
Yes No
# of miles (one way): 
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
Vehicle Information:
(include all cars you or your business owns or leases) 
Car #2
Year
Make
Model
Sub Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Mileage
Drive to school, work, station?
Yes No
# of miles (one way): 
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
Vehicle Information:
(include all cars you or your business owns or leases) 
Car #3
Year
Make
Model
Sub Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Mileage
Drive to school, work, station?
Yes No
# of miles (one way): 
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
Vehicle Information:
(include all cars you or your business owns or leases) 
Car #4
Year
Make
Model
Sub Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Mileage
Drive to school, work, station?
Yes No
# of miles (one way): 
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
Vehicle Information:
(include all cars you or your business owns or leases) 
Car #5
Year
Make
Model
Sub Model
Body Type
Vehicle ID# (VIN)
Name of Title Holder
Annual Mileage
Drive to school, work, station?
Yes No
# of miles (one way): 
Car equipped w/ airbags?
Yes No
Anti-theft devices?
Yes No
Driver History
If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 5 years?
Yes No
    If yes, please answer the following:

Driver
Date
Type of Conviction
Speed
Over Limit
Suspended
Revoked
MPH
Yes
Yes
MPH
Yes
Yes
MPH
Yes
Yes
MPH
Yes
Yes
MPH
Yes
Yes
Additional Comments:
Please give any additional comments about the coverage you desire: