Tashjian Insurance Agency, Inc. is committed to providing you with the best in customer service. By filling out this questionnaire you will have a custom quote prepared for you the next business day. For your convenience Tashjian Insurance Agency, Inc. keeps their fax lines open at all times in case you prefer to print out this form and fax it instead of submitting it online.

Contact Information:

 Contact Name:  

Contact Phone:

Contact Email:

 Street Address:

 City: State: Zip Code:

Driver Information:

 Number of Drivers: Number of Cars:

  

 

Driver #1	Driver # 2	Driver # 3
Name:	Name:	Name:
D.O.B.:	D.O.B.:	D.O.B.:
Year Licensed:	Year Licensed:	Year Licensed:
# of Tickets on Record:	# of Tickets on Record:	# of Tickets on Record:
# of at Fault Accidents:	# of at Fault Accidents:	# of at Fault Accidents:

 

Vehicle Information

Vehicle #1	Vehicle #2	Vehicle #3
Year:	Year:	Year:
Make:	Make:	Make:
Model:	Model:	Model:
Annual Miles:	Annual Miles:	Annual Miles:

 

 

ADDITIONAL DRIVERS & VEHICLES / COMMENTS: