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BUSINESS 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:  

 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: