Capitol Benefits LLC
Insurance Agency in Gaithersburg, MD
Please complete this worksheet for the property location address printed below.
In the event of a loss, would you select the reconstruction of your home to be of modern materials or exact replica materials?
Modern Materials (Examples: Sheetrock/Drywall walls, 8 foot ceilings, Standard Wood, Concrete Foundation)Exact Replica Materials (Examples: Plaster Walls, 10 foot ceilings, Rough Lumber)
Bi-level / Raised Ranch
1 ½ Story
Number of stories: 11½22½3
An Attached Garage
A Built-In Garage
A Basement Garage
For each category indicate the percentage of each type of material used in your home. Please ensure each column adds to 100%. If your home contains a material not listed, please write-in the material name and percentage under "Other - Specify".
Wood Shingles Shakes
Metal (Tin, Steel)
Built-up / Tar & Gravel
Corian, Granite or Authentic Marble Counter topsMore than one ovenCenter Island with Cabinets or SinkCommercial style Refrigerator (e.g. Sub-Zero style)6 or more total range top burners
The home must be currently hooked up to a monitoring system (ie. ADT).
By submitting this form, I acknowledge that the information I have provided in this survey is accurate and complete to the best of my knowledge. I hereby release this information to be used by Capitol Benefits in reviewing the current Coverage A limit of my homeowners.
Customer Signature: Type your full name.
Capitol Benefits, LLC
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