Subscriber Questions

Takaful Tire insurance!

In order to proceed the Takaful Tire Insurance Subscriber Questions form Please click on the button Below.

Subscriber Questions Form

Takaful Tire Subscriber Questions

I understand that by answering the following questions, Takaful Tire Insurance Company, a reciprocal inter-insurance exchange, is not selling me any type of insurance policy including personal auto coverage at this time.

I understand that the purpose for completing the following question(s) is solely for Takaful Tire Insurance Company to meet the requirements set forth pursuant to Minn. Stat. 71A.02, subd. 2(6), which in part, provides, ". . . that applications have been made for indemnity upon at least 100 separate risks aggregating not less than $1,500,000, as represented by executed contracts or bona fide applications, to become concurrently effective, . . ."

I understand that, by completing the following questions, I am a bona fide applicant subscribing to Takaful Tire Insurance Company’s Reciprocal Insurance.

Are you a resident of Minnesota? *
Yes No

What is your resident state? *

First Name *

Middle Name

last Name *

Phone *

Email Address

How many members are in your household that have either a driving permit or license? *

How many cars does your household own that requires an insurance? The initial minimum subscription quote for each car of the household is $99.00. *

Total:

How much do you currently pay for personal auto coverage? *

Are you willing to add more money into your reciprocal subscription besides the minimum required of $99.00 per car? *
Yes No

How much more? *

Total *

I, . state the following:

That I am the head of my household,

That by completing this form, I agree to become a bona fide applicant and subscribing to a reciprocal inter-insurance exchange to be provided by Takaful Tire Insurance Company,

That as a bona fide applicant, my total subscriptions for the reciprocal inter-insurance exchange are $0,

That the above statements and answers are true and correct to the best of my knowledge,

AND

That I consent to the use of the information I provided here by third party(ies) for the sole purpose of the Takaful Tire Insurance Company’s reciprocal inter-insurance exchange application to the State of Minnesota.

By submitting this form, I agree to all of the above terms and conditions. *
Agree Disagree

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Takaful Tire Subscriber Questions