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Personal Lines Questionnaire
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262-342-1020

Personal Lines Questionnaire

This questionnaire is intended to start the quoting process.

We will call you shortly after completion to collect additional needed information.
Thank you for choosing the Weis Group and Robertson Ryan for your insurance needs.

Named Insured(Required)

First Last

Names and Birthdates of any other household members(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender Identification(Required)

Home Address(Required)

Street Address Address Line 2 City State Zip Code

Phone(Required)

Email(Required)

Home

Residence Type(Required)

Primary Residence

Secondary Residence

Is this a Rental/ Income Property?(Required)

Yes

No

Year Built(Required)

Year Purchased(Required)

Home Square Feet(Required)

If you have a garage, which best describes it?(Required)

Attached

Detached

Number of Garage Stalls(Required)

Roof Type(Required)

Asphalt Shingles

Ceramic Tile/ Slate

Wood Shake

Flat - Tar Gravel

Flat - Rubber Membrane

Other

When roof was last replaced?(Required)

Number of Fireplaces(Required)

If you have a Fireplace, what type?(Required)

Gas

Wood

Both

Is there a Wood Stove(Required)

Yes

No

Do you have a Basement?(Required)

Yes

No

If yes, you have a basement, is it finished?

Yes

No

Is there a Sump Pump?(Required)

Yes

No

If yes, you have a Sump Pump, does it have a battery backup?

Yes

No

Is there a swimming pool?(Required)

Yes

No

Is there a Trampoline?(Required)

Yes

No

Pets or animals on premises? If yes, how many and what breed?(Required)

Occupation(Required)

Homeowners Deductible(Required)

Auto

Drivers License Number(Required)

Auto #1

Year(Required)

Make(Required)

Model(Required)

Auto VIN(Required)

Miles Driven Annually(Required)

Type of Coverage...(Required)

Full Coverage

Liability Only

Deductibles?(Required)

Any Claims? Accidents? Violations?(Required)

Auto #2

Auto VIN Copy

Year

Make

Model

Auto VIN

Miles Driven Annually