Personal Information
Name
Email Address
Date of Birth
Additional Name
Address
City/County
State/Zip Code
Home Phone
Work Phone
Best Way to Contact You and When
Employer
Occupation
Home Information
Year Built
Style of Home (ranch, 2 story, bi-level, etc)
Total Square Footage
Exterior Material On the Building
Brick Frame Aluminum Stucco
Roof Material On the Building
Shingles Wood Shake Tar & Gravel Other How old?
Cost to Rebuild
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 Dwelling Coverage Amount
Requested Liability Limit
Requested Deductible
Insurance Information
What's the name of your current homowners/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.
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
