Taake Insurance Homeowners Quote Form
Taake Insurance, is licensed to sell insurance in the State of Illinois. 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, 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:
Address:
City:
State:
ZIP:
County:
Email:
Evening Phone:
(
) -
Day Phone:
(
) -
Best time to call:
am
pm
Current Homeowners Insurance Company (not agency):
Company Name:
Policy Exp. Date:
/
/
Amount Insured For:
$
Home Information
Year home was built:
Security Alarm:
Local
Central
Construction:
Frame or Masonry
Masonry or Veneer
Masonry
Other
Distance to Fire Department:
Under 5 Miles
Over 5 Miles
In City Limits:
Yes
No
Additional Comments:
Please give any additional comments about the coverage you desire:
