Homeowner Quotation

Your Email Address (to receive a copy of your submission)

How did you hear about us? How did you hear about us? Referral I am a current client Media Ad Google Other

May we ask who referred you?

First Name

Last Name

Address

City

Postal Code

Ext.

Main Phone

Email Address

Date of birth

Occupation (Possible discounts)

Is there a co-applicant? Is there a co-applicant? Yes No

Co-applicant Full Name

What is the Co-applicants email?

What is the co-applicants Occupation?

What is the co-applicant's date of birth?

Do you, the owner, occupy the dwelling? Do you, the owner, occupy the dwelling? Yes No

Is the location to be insured the same as your mailing address? Is the location to be insured the same as your mailing address? Yes No

Is the home... Is the home... *One storeyTwo storeyOther

Select the structure type of the dwelling. Select the structure type of the dwelling. *DetachedSemi-detachedTownhouse

What year was it built?

What is the above grade square footage?

Is there a garage for the property? Is there a garage for the property? *Attached one carAttached two carAttached three-carDetachedNoneOther

Please Specify

What is the exterior finishing? What is the exterior finishing? *Vinyl sidingCement fiber (Hardie board)StuccoWood SidingAluminum SidingOther

Please Specify

What is the roofing material? What is the roofing material? *Asphalt shinglesClass IV impact resistant asphalt shinglesWood shakesRubber tileConcrete TileMetalOther

Please Specify

Is the basement... Is the basement... *RegularWalkoutOther

Please Specify

Approximately what percentage of the basement footprint is developed?

Is there a sump pump in the basement? Is there a sump pump in the basement? Yes No Unknown

Does the sump pump have a backup power supply? Does the sump pump have a backup power supply? Yes No

Is there a back-flow valve on the sewer line? Is there a back-flow valve on the sewer line? Yes No Unknown

Is there an attached deck on the house? Is there an attached deck on the house? Yes No

What is the approximate square footage?

What year was the roof last replaced?

What year was the furnace last replaced?

(furnace) If more than 10 years ago, when was it last serviced?

What year was the hot water system last replaced?

Have there been any modifications or updates to the electrical or plumbing systems?

How many full and half bathrooms in the home?

Is there a centrally monitored alarm system in the home? Is there a centrally monitored alarm system in the home? *BurglarFireBothNot Applicable

How many mortgages on the property? How many mortgages on the property? *0123More than 3

Do you currently hold any form of property insurance (Homeowner, Tenant, Condo, etc.)? Do you currently hold any form of property insurance (Homeowner, Tenant, Condo, etc.)? Yes No

How many years have you held property insurance of one form or another?

What is the name of your current property insurance company?

How many years have you been with your current company? How many years have you been with your current company? *12345 or more

Have you had any claims on your property insurance in the past five years? Have you had any claims on your property insurance in the past five years? *0123 or more

Please provide an approximate date for your claims(s) along with a brief description (hail, burglary, fire, etc.).

Do you rent any part of the home to others? Do you rent any part of the home to others? Yes No

Are there any smokers living in the home? Are there any smokers living in the home? Yes No

Are there any businesses operating from the home? Are there any businesses operating from the home? Yes No

Do you agree to Our Terms and Conditions? Do you agree to Our Terms and Conditions? I agree to the Touchstone Insurance Quotation Terms & Conditions