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
yrs.
Annualized Payroll:
$
Annual Sales
$
Please give a brief description of your business and clientel:
Please select the type of coverages you want:
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Property / Premises Information 1
Street Address:
Owner
Tenant
Year Built:
% Occupied
Sprinklers?:
Yes
No
Construction Type:
Frame
Concrete
Metal
Burglar Alarm:
Yes
No
Building Value: $
Contents: $
Other Property ( Specify)
Property / Premises Information 2
Street Address:
Owner
Tenant
Year Built:
% Occupied
Sprinklers?:
Yes
No
Construction Type:
Frame
Concrete
Metal
Burglar Alarm:
Yes
No
Building Value: $
Contents: $
Other Property ( Specify)
Property / Premises Information 3
Street Address:
Owner
Tenant
Year Built:
% Occupied
Sprinklers?:
Yes
No
Construction Type:
Frame
Concrete
Metal
Burglar Alarm:
Yes
No
Building Value: $
Contents: $
Other Property ( Specify)
Liability
Class of Business:
Contractor / Building Trades
Contractor / Professional Services
Retail
Professional Office
Truckers
Other
# of employees:
Percentage of any Subcontracted Work:
Limits Requested:
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years:
Workers Compansation
Federal Information:
Federal I.D. Number
If known, describe any claims you've had in the past 5 years:
Rating Information:
Classification Description
(By Employee Group)
Annual Payroll
(By Group)
Names of Owners / Corporate Officers:
Do you want to include or exclude owners/officers:
Include
Exclude
Additional Comments:
Please give any additional comments about the coverage you desire:
