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Renters Quote
Form: Renters Insurance Quote Form
Renters Insurance Quote Form




Contact Information
Full Name:
Day Telephone:
Street Address:
Eve Telephone:
City, State & Zip:
Fax:
E-Mail Address:
Your occupation:
Best Time To Reach You:
Date of Birth:
Social Security #
Current Insurance Information
Insurance Company Name:
(NOT Insurance Agency/Broker)
Policy Exp. Date:
$ Contents Insured for:
Current Ded:
Premium Amt:
Policy Term:
General Information
Will you or do you live on this property:
yes no
How much coverage do you want on your personal property:
$
How much personal liability:
$100,000 $300,000
$500,000 $1,000,000
Deductible:
$500 $750 $1,000
$2,000
Number of Units:
Number of Stories:
Is there a 24-hour door man:
yes no
Are there elevators:
yes no
Year Built:
(yyyy)
Approximate Square Feet:
Have you reported any claims or losses to your insurance company within the last 5 years
yes no
Type of Construction:
brick wood frame
cinder block other
Roof Type:
composite shingle tile
wood shingle other
Roof Age:
years (if unknown, please indicate)
Burglar Alarm:
yes no
Heating System:
forced air electric boiler
oil propane
Number of gas or wood fireplaces or stoves:
What floor do you live on:
Number of bathrooms:
Additional Information
Any business conducted in home: (if yes, please describe)
 yes no
List values of any jewelry, furs, or specialty items:
List pets & breeds:
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.


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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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