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PERSONAL AUTOMOBILE QUESTIONNAIRE
For your convenience Tashjian Insurance Agency, Inc. keeps their fax lines open at all times. Please print out this sheet and fax it to 626.357.5037.
Contact Information:
Contact Name:
Contact Phone:
E-Mail Address:
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: