Michael Palermo & Associates Insurance Limited

CAR QUOTE

We invite yon to inquire about a premium quotation. The information you provide will be held in the strictest confidence.

Please note that your inquiry about a quotation does not bind you to the acceptance of the quotation nor does it impose upon you the obligation to accept the quote for the purpose of creating a contract. The contract for insurance is not created until there is agreement by you in writing as to your acceptance of the coverages, premium cost and the conditions and provisions of the insurance wordings.

If you would rather speak to one of our sales representatives, please call us at 905-761-9645 - Toronto Line: 416-247-5471 - Toll Free: 1-888-343-5575

PERSONAL INFORMATION
NAME:
EMAIL:
PHONE:
CITY/TOWN:
POSTAL CODE:
How many consecutive years have you been insured in Canada without any interruption of coverage?	years months
Have you had any insurance cancellations for non-payment in the last three years?	Yes No
VEHICLE INFORMATION
Vehicle 1: *Vehicle Particulars and Use*
Year:
Make: (ie: Pontiac)
Model: (ie: Grand Am)
Body Type
Annual km driven:
Vehicle use:
Commute distance one-way:
*Insurance Coverages Required*
Liability:
Comprehensive deductible:
Collision deductible:
Optional coverages:	Loss of Use (replacement car coverage) Non-owned vehicle coverage (for rental car coverage)
Vehicle 2:
Year:
Make: (ie: Pontiac)
Model: (ie: Grand Am)
Body Type
Annual km driven:
Vehicle use:
Commute distance one-way:
*Insurance Coverages Required*
Liability:
Comprehensive deductible:
Collision deductible:
Optional coverages:	Loss of Use (replacement car coverage) Non-owned vehicle coverage (for rental car coverage)
DRIVER INFORMATION
Driver 1:
Name:
Age:
Date 1st Licensed in Canada: (YYYY/MM/DD)
Driver Training:	Yes No
Driver 2:
Name:
Age:
Date 1st Licensed in Canada: (YYYY/MM/DD)
Driver Training:	Yes No
Driver 3:
Name:
Age:
Date 1st Licensed in Canada: (YYYY/MM/DD)
Driver Training:	Yes No
CLAIMS & CONVICTION INFORMATION It is important to understand the difference between claims and accidents. You could have your radio stolen or windshield replaced and report a claim and still have no accidents
Please list all claims for the above listed drivers in the last six years. include: driver name, date of claim, claim payout and other details
Please list all convictions (ie. speeding tickets, seat belt tickets but not parking tickets) for each of the above listed drivers. include: driver name, date of conviction, and other details
How would you like us to contact you?	email phone
Before submitting this quote request to our office, please leave us any comments you may have (i.e. additional information on any of the above questions).
Please note that your inquiry about a quotation does not bind you to the acceptance of the quotation nor does it impose upon you the obligation to accept the quote for the purpose of creating a contract. The contract for insurance is not created until there is agreement by you in writing as to your acceptance of the coverages, premium cost and the conditions and provisions of the insurance wordings. `I have read and understand the above statement.` To submit please type the word YES in this box:

Michael Palermo & Associates Insurance Limited
7501 Keele Street, Suite 501, Concord, ON, L4K 1Y2

Phone: 905-761-9645 - Toronto Line: 416-247-5471 - Toll Free: 1-888-343-5575
Fax: 905-761-9808 - Toronto Fax: 416-247-6914
info@palermoinsurance.com