Please complete this worksheet for the property location address printed below.

    1. In the event of a loss, would you select the reconstruction of your home to be of modern materials or exact replica materials?

    2. Town House

      Number of stories: 123

    3. A Basement Garage

      Detached Garage


    5. Basement %:
      Crawl Space %:
      Slab %:
    6. Is it a walkout? YesNo
      What percentage is finished?
      If finished, finish style: StandardCustom
    7. 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".

      Exterior Walls % Floor Finishes %
      Brick (Solid) Hardwood
      Brick Veneer / Brick on Frame Carpet
      Concrete Block Carpet over Hardwood
      Stone (Solid) Ceramic Tile
      Stone Veneer / Stone on Frame Clay Tile
      Stucco on Block Marble / Granite / Solid Stone
      Stucco on Frame Slate / Brick / Flagstone
      Wood Siding / Shakes Vinyl
      Vinyl / Aluminum Siding
      Other wall Other floor
    8. Feature Year
      Heating/Air Conditioning
    10. Wood Deck:
      Composite Deck:
    11. Please indicate if any of your kitchens have the following special features:

    12. Full (tub/shower, sink & toilet):
      Half (sink & toilet):
      Please indicate the number of bathrooms that have the following special features:
      Feature Qty
      Corian, Granite or Marble
      Spa or Jacuzzi Tub
      Double Sink
      Bathtub and separate Shower Stall
    13. Windows Doors & Fireplace
      Skylights Atrium/French Doors
      Bay Windows Sliding Glass Doors
      Bow Windows Fireplace
      Picture Windows

    14. 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.

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