LIFE/HEALTH QUESTIONNAIRE

 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 incase you 

 prefer to print out this form and fax it instead of submitting it online.

General Information:

 Contact Name:  

 Contact Phone: E-Mail Address:  

 Street Address:

 City: State: Zip Code:

 Applicant D.O.B:. Applicant Gender:

 Applicant Height: Applicant Weight:

 Does Applicant Smoke? YES  NO     

 Does Applicant Drink? YES  NO  ONLY SOCIALLY

 COMMENTS/REMARKS