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:  

 Business Name:  

 Contact Phone: E-Mail Address:  

 Street Address:

 City: State: Zip Code:

 

 

Business Description:

 

 

Vehicle Information:

Vehicle #1	Vehicle #2	Vehicle #3
Year:	Year:	Year:
Make:	Make:	Make:
Model:	Model:	Model:
Annual Miles:	Annual Miles:	Annual Miles:
GVW:	GVW:	GVW:
Radius of Use:	Radius of Use:	Radius of Use:
Garaging Zip Code:	Garaging Zip Code:	Garaging Zip Code:

 

Coverage Information:

 Limited Liability:

 Medical Limit:

 Uninsured Motorist:

 Comprehensive Deductible:

 Collision Deductible:

 

 

 Additional Vehicles/Comments: