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

1. In what year was your home built?
   

2. For homes built prior to 1940:

   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)

3. Is your home:
   One FamilyTwo FamilyThree FamilyFour Family

4. Please select the style that most resembles your home.

   

   1 Story

   

   2 Story
   3 Story

   

   Victorian

   

   Split-Level
   Tri-Level
   Back Split

   

   Bi-level / Raised Ranch
   2 Levels

   

   1 ½ Story

   

   Adobe

   

   Town House
   End Unit
   Center Unit

   

   Contemporary

   Number of stories: 11½22½3

5. Do you have a garage or carport?
   YesNo

   

    
   An Attached Garage

   (no living space above)

   

   A Built-In Garage

   (living space above)

   
    

   A Carport
    

   

   A Basement Garage

   

   Detached Garage
    
    

 

 

Total Living Area, excluding Basement and attic:


Foundation Type: (Must add up to 100%)

Basement %:

Crawl Space %:

Slab %:

If you have a basement:

Is it a walkout? YesNo

What percentage is finished?

If finished, finish style: StandardCustom

Please select the materials that describe those found in your home.

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

Please provide the approximate year the following were updated:

Feature	Year
Roof
Plumbing
Heating/Air Conditioning
Electrical

Please select the primary roofing material on your home.



Shingles



Wood Shingles Shakes



Clay/Concrete Tile



Metal (Tin, Steel)



Slate



Built-up / Tar & Gravel



Other

 

 

Do you have a:

Wood Deck:

Composite Deck:

Porch:

EnclosedScreenedOpen

How many kitchens are in your home? -

Please indicate if any of your kitchens have the following special features:

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

How many bathrooms are in your home?

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

Please enter the number of these additional features in your home:

Windows			Doors & Fireplace
Skylights			Atrium/French Doors
Bay Windows			Sliding Glass Doors
Bow Windows			Fireplace
Picture Windows

Please note any other features of your home that may cost more than $10,000 to replace in the event of a loss (i.e. Lanai, Sun Room, Greenhouse, etc.).


How many years have you lived at this residence?


Do you have and active alarm system?

The home must be currently hooked up to a monitoring system (ie. ADT).

YesNo

Do you have a dog? If yes, what breed?
YesNo

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.