HOME INSURANCE 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 in case 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:

 

Dwelling Information:

 Year Built: Square Footage:  

 

 Roof Type: Please Choose Tile Wood Shingle Flat Roof Asphalt Shingle Rock Roof

 

 Fireplace Yes No

 Foundation Slab Raised Bolted Yes No

 Central Air Yes No 

 

 Pool Yes No

 

 # Bedrooms: # Bathrooms: # Floors:

 

 Primary Use: Primary Residence Rental Dwelling Secondary Residence

Additional Features:

 Central Alarm Yes No 

 

 Fire Sprinklers Yes No

 

 Enclosed Patio Yes No

 

 Central Vacuum Yes No

 

 Sky Lights Yes No

 

 Marble Tile Yes No

Dwelling Improvements: Check All That Apply

 Roof: Yes No     

 

 Plumbing: Yes No    

 

 Electrical: Yes No     

 

 Heating: Yes No  

 

 Exterior Paint: Yes No  

 

Comments/Remarks: