Personal Information
Name
Email Address
Date of Birth
Additional Name
Address
Unit #
City/County
/
State/Zip Code
Select a state/province Alabama Alaska Alberta, Canada Arizona Arkansas California Canada-Alberta Canada-New Brunswick Canada-Ontario Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick, Canada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario, Canada Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming /
Home Phone
Work Phone
Best way to contact you and when
Employer
Occupation
Name of Condo Association
Property Information
# of Units in the Building
Exterior Material On the Building (i.e. brick, frame /aluminum, stucco, fire resistive)
Brick Frame Aluminum Stucco
Do you have a pet? What kind?
Do you have an in home business? What kind?
Do you have any of the following?
Smoke Alarm
Deadbolt Lock
Fire Extinguisher
Sprinkler System
Burglar Alarm
Coverage Information
Requested Additions and Alterations Coverage Amount (amount to replace all cabinets, fixtures, and all other items attached to the walls.)
Requested Personal Property Amount
Requested Liability Limit
Requested Deductible
Insurance Information
What's the name of your current homeowners/renters insurance company
and expiration date?
What's the name of your current auto insurance company
Have you had any claims with either in the past 5 years?
If yes please explain.
We also offer insurance for the following items: jewelry, furs, fine art, silverware, guns, cameras, boats, computers, and other valuable items. Please let us know the items you would like to insure on your policy.
Your social security number is needed to obtain your credit report in order to provide a quote. Please indicate the best time to call to obtain this information.
Contact Phone
Best Time to Call
I/We Authorize Draper and Kramer Agency Corporation to obtain the necessary consumer and insurance information including a credit report to determine insurability and rating.
Copyright ©2005, Draper and Kramer, Incorporated
