Drass Insurance Agency, INC

Find the Right Insurance

Zip Code:

Type of Insurance:

Home Details

Year Home Was Built:

Number of Stories:

Type of Property:

Type of Garage:

Type of Basement:

Home Security:

Type of Roof:

Exterior Walls:

Inside Your Home

Square Footage (excluding basement):

Number of Bedrooms:

Number of Full Bathrooms (with shower/bath tub):

Number of Half Bathrooms (without shower/bath tub):

Number of Fireplaces:

Number of Decks:

Potential Discounts:

Deadbolts
Smoke Alarms
Fire Extinguishers
Nearby Fire Station
Nearby Fire Hydrant

Add-ons:

Central A.C.
Sauna
Hot Tub
Wood Burning Stove
Sump Pump
Swimming Pool

Do you own any dogs of these breeds?

Rottweiler
Pitbull
German Shepherd
Chow
Doberman

Info

Do you currently have home insurance coverage?

Current Insurance Carrier:

When does your existing policy expire?

Estimated Replacement Cost:

Info

Deductible:

Liability Protection:

Do you need sewer backup protection?

Yes
No

Do you need earthquake protection?

Yes
No

Is there a smoker in your household?

Yes
No

Claims

How many claims would you like to report within the last 5 years?

First Claim:

Second Claim:

Third Claim:

Fourth Claim:

First Claim:

Second Claim:

Third Claim:

Fourth Claim:

Fifth Claim:

First Claim:

Second Claim:

Third Claim:

Fourth Claim:

Fifth Claim:

Sixth Claim:

Valuable Items

What additional valuable items would you like to insure? (check all that apply)

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Address:

City:

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First Name:

Last Name:

Email:

Phone Number:

Birthdate:

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