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Thank you for choosing Robertson Ryan, and the Kirk Group for your insurance needs!

This questionnaire is intended to start the quoting process. We will call you shortly after completion to collect additional needed information.

If you are part of a Condominium or HOA, what is its name?

If the Home titled in the name of a Trust, please list

Home Address(Required)

Address Address Line 2 City State Zip Code

Residence Type(Required)

Primary Residence

Secondary Residence

Is this a Rental/ Income Property?(Required)

Yes

No

Year Built(Required)

Year Purchased(Required)

Home Sq. Ft.(Required)

If you have a Garage, which best describes it?

Attached

Detached

Garage Sq. Ft.(Required)

Number of Garage Stalls(Required)

Roof Type

Asphalt Shingles

Ceramic Tile/ Slate

Wood Shake

Flat – Tar Gravel

Flat – Rubber Membrane

Other

Age of Roof (Years)(Required)

Age of Electrical (Years)(Required)

Age of Heating & Air Conditioners (Years)(Required)

Age of Plumbing (Years)(Required)

Number of Bathrooms(Required)

Number of Fireplaces(Required)

If you have a Fireplace, what type?

Gas

Wood

Both

Is there a Wood Stove?(Required)

Yes

No

Do you have a Basement?(Required)

Yes

No

Is there a Sump Pump?(Required)

Yes

No

If yes, you have a basement, it is finished?(Required)

Yes

No

Does the Sump Pump have a battery backup?(Required)

Yes

No

Is there a swimming pool?(Required)

Yes

No

Is there a trampoline?(Required)

Yes

No

Type of Heating?(Required)

Forced Air

Radiator

Other

Central Air?(Required)

Yes

No

List all Pets(Required)

If there is a home business, please describe.(Required)

Person 1

Name(Required)

First Last

Untitled

Date of Birth

MM slash DD slash YYYY

Email

Gender Identification(Required)

Marital Status (Discounts May Apply)(Required)

Phone Number(Required)

Highest Level of Education (Discounts May Apply)

High School

Associates

Some College

Bachelors

Graduate

Doctorate

Drivers License Number(Required)

Auto Make(Required)

Auto Model(Required)

Auto Year(Required)

Auto Vin(Required)

Miles Driven Annually(Required)

Do you use this Auto for Business Purposes?

Yes

No

Person 2

Name

First Last

Date of Birth

MM slash DD slash YYYY

Email

Gender Identification

Marital Status (Discounts May Apply)

Phone Number

Highest Level of Education (Discounts May Apply)

High School

Associates

Some College

Bachelors

Graduate

Doctorate

Drivers License Number

Auto Make

Auto Model

Auto Year

Auto Vin

Miles Driven Annually

Do you use this Auto for Business Purposes?

Yes

No

If any additional drivers in household, please list:

Please check the box below

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