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Property Liability Quote
Commercial Property Insurance Quote

Contact Information
Name of Business:
Contact Name:
Premises Address:
City:
 State: Zip:
Business Phone:
 Fax Number:
Contact Email Address:
Years in Business:
Description of Operations
or SIC code(s):
Current Insurance Information
Current Insurance Carrier:
Premium: $ Expiration Date:
Annual Sales: $ Payroll: $ Business Income: $
Other Insurance Company Used Within Past 3 Years:
Policy #:
Losses past 3 years: Amount paid for each loss: $
Description of losses or loss runs:
Coverage's Desired
Liability Limit Desired: Deductible Desired:
Or choose other liability limit amount: $
Umbrella Amount Desired:
Building 1
Building Value: $ Contents Value: $
Total Building Area: Year Built:
Construction Type: Sprinklers:
Electrical Type: Amps:
Electrical Renovation Year:
Plumbing Renovation: Plumbing Renovation Year:
Heating Type: Heating Renovation Year:
Roofing Renovation: Roof Age (years):
Central Alarm:

List Neighboring Businesses:
To the right: Distance:
To the left: Distance:
To the rear: Distance:
Building 2
Building Value: $ Contents Value: $
Total Building Area: Year Built:
Construction Type: Sprinklers:
Electrical Type: Amps:
Electrical Renovation Year:
Plumbing Renovation: Plumbing Renovation Year:
Heating Type: Heating Renovation Year:
Roofing Renovation: Roof Age (years):
Central Alarm:

List Neighboring Businesses:
To the right: Distance:
To the left: Distance:
To the rear: Distance:
Additional Comments
Please give any additional comments or questions

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Palomino Insurance Agency

Corporate Office

8889 E. Bell Rd #201
Scottsdale, AZ 85260 
Office # 480-483-8000

California  Office

Serving Los Angeles, San Diego
& Orange County
26359 Jefferson Ave #D
Murrrieta, CA 92562
Office # 949-300-2050

License Information:

AZ Palomino Agency Department of Insurance License #910284
AZ Mike Palomiono Az Department of Insurance License #704684
CA Individual Approved License #0H39335
CA Broker Corp LIC #OH58343
UT Mike Palomio Individual. #375139

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