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:

 Number of Years in Business:

 Total Number of Employees: Total Annual Payroll:

 Number of office Employees: Office Employee Payroll:

 Number of Outside Sales Personnel: Outside Sales Payroll:

 Number of Employee Injuries in Past Three Years: