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)


      Brick Veneer / Brick on Frame


      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 / Aluminum Siding

      Other wall

      Other floor

    8. Feature




      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:



      Corian, Granite or Marble

      Spa or Jacuzzi Tub

      Double Sink

      Bathtub and separate Shower Stall

    13. Windows

      Doors & Fireplace


      Atrium/French Doors

      Bay Windows

      Sliding Glass Doors

      Bow Windows


      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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