Michael Palermo & Associates Insurance Limited

HOME ISURANCE QUOTE

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 years have you had property insurance?	years months
YOUR HOME
Year Built:
Building Type :
Fire protection.(check all that aply)	within 300m (1000ft) of a fire hydrant within 8km (5 miles) of a fire hall unprotected
COVERAGES REQUIRED
Dwelling building. (replacement cost of house, not market value. Coverage "A" on your current policy)
Legal Liability. (coverage "E" on your current policy)
OPTIONAL COVERAGES All house insurance policies contain coverage limitations for valuable items such as jewellery, furs, fine arts, silverware and collectibles. You can list these items separately on your policy for an additional premium to ensure full coverage is applied. If you require additional coverage, please provide details below:
Value of items to be insured	Jewellery Furs Fine Arts Silverware Other:
Other Locations (cottage or rental property):
Name of city/township.
Postal code.
Year built.
Dwelling value. (coverage "A" on your current policy)
Personal property. (coverage "C" on your current policy)
Fire protection.(check all that aply)	within 300m (1000ft) of a fire hydrant within 8km (5 miles) of a fire hall unprotected
DISCOUNTS Please check all of the discounts you may be eligible for.
Age (what year were you born:)
Alarm - burglar, is it centrally monitored:	yes no
Alarm - fire, is it centrally monitored:	yes no
Claims free (no claims in last three years)
Mortgage free
Non-smoker
CLAIMS HISTORY
Please list all claims you have made against your insurance policy within the past five years. Examples of claim types include water damage, fire and theft.. include: date of claim, description of claim, amount paid for claim
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