Replacement Cost Estimator Please complete this worksheet for the property location address printed below. Name: Address: Phone: Email: Insurance Agent: In what year was your home built? 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) Is your home: One FamilyTwo FamilyThree FamilyFour Family 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 Do you have a garage or carport? YesNo An Attached Garage (no living space above) # of Cars: A Built-In Garage (living space above) # of Cars: A Carport # of Cars: A Basement Garage # of Cars: Detached Garage # of Cars: 6. Total Living Area, excluding basement and attic: Sq.ft 7. 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 10. 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 Other 11. Please provide the approximate year the following were updated: Feature Year Roof Plumbing Heating/Air Conditioning Electrical 12. Please select the primary roofing material on your home. Shingles Asphalt/Composition Wood Shingles Shakes Clay/Concrete Tile Metal (Tin, Steel) Slate Built-up / Tar & Gravel Other: 13. Do you have a: Wood Deck: Total Sq.ft Composite Deck: Total Sq.ft Porch: Total Sq.ft EnclosedScreenedOpen 14. How many kitchens are in your home? - Total Sq. ft 15.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 16. How many bathrooms are in your home? Full (tub/shower, sink & toilet): Half (sink & toilet): 17. 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 18. Please select the number of these additional features in your home: Windows Doors & Fireplace Skylights 012345 Atrium/French Doors 012345 Bay Windows 012345 Sliding Glass Doors 012345 Bow Windows 012345 Fireplace 012345 Picture Windows 012345 19. 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.). 20. How many years have you lived at this residence? 21. Type of heating: 22. Do you have an active alarm system? (The home must be currently hooked up to a monitoring system (ie. ADT) YesNo 23. 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. Rebuild Materials: You only need to answer this question if your home was built prior to 1940. If your home was built in 1940 or later, please leave this question blank and proceed to Question 3. Modern Materials - Select this option if your home was built prior to 1940 and you would like newer materials (such as drywall instead of plaster, etc) to be used to repair or rebuild your property in the event of a loss. Exact Replica Materials - Select this option if your home was built prior to 1940 and you would like replica materials (such as plaster, rough lumber, etc) to be used to repair or rebuild your property in the event of a loss. By selecting Exact Replica Materials, you may increase the cost of rebuilding your home, coverage amount and premium on your policy. Calculating Total Living Area: The total living area is the size of your home (in square feet) based upon the outside measurements. It is the length of the home multiplied by the width of the home multiplied by the number of stories. It includes built-in garages but not basements, porches, decks or breezeways. You may know the square footage of your home from real estate or tax assessment documents. Please note: For 1-1/2 story homes, multiply the living area of the first floor by 1.65 and for 2-1/2 story homes, multiply the living area of the first floor by 2.65. Foundation Type / Basement Selections: Crawl Space - ½ the height of a basement, allowing entrance to space by crawling or crouching. Floor may be slab, dirt or plastic over dirt. Slab - The frame of the home is built directly onto a slab of poured concrete or equivalent leaving no form of entrance and no room for storage below the first floor. Interior floor is built on top of slab. Walkout Basement - Normally built on a sloping site where the foundation walls are partially exposed with windows and a door. Can also be referred to as a “daylight basement” or walkout cellar. It allows you to stand full height, is accessible by stairs within the house and can be entered from outside by walk-in door or sliders. Finished Basement Types: Standard - Generally has interior painted drywall partitions with hollow core doors, painted drywall ceiling, carpet and/or vinyl floor finishes and standard electrical outlets, lighting and heating. Custom - Generally upgraded finishes to include ample interior drywall partitions with solid core doors, painted drywall ceiling and linear wood ceiling, partial millwork paneling and painted drywall finishes, high quality carpet, ample electrical outlets and lighting, heating and air conditioning systems. Roof - For a roof with asphalt shingles, either completely covering the existing layer of shingles with a new layer of asphalt shingles, up to a maximum of 2 layers, or completely replacing the current layer of shingles. For metal, wood, tile, or slate roofs, enter the year it was removed and replaced. Plumbing - The year plumbing was updated to conform to current local codes with new water supply lines or when new plumbing fixtures and components were installed throughout the dwelling. Heating/Air Conditions - For heating, complete replacement of the heating plant or heat exchanger. For cooling, replacement of the central air conditioning unit or a/c compressor. Electrical - Replacement of fuse or breaker boxes, and updating breaker boxes to conform to local codes and meet system demands, would be examples of updates. Other examples would include replacing switches, wiring, fixtures, and components necessary to meet system demands. Roofing Material: Shingles Asphalt/Composition - Shingles made of felt or inorganic fiberglass saturated with asphalt and surfaced with mineral granules. Also called composition shingles, these may be made in individual strips, interlocking and self-sealing. Asphalt shingles are normally applied on medium pitched roofs over solid sheathing and a vapor barrier. Wood Shingles Shakes - Shakes split from a bolt of wood, generally in random dimensions. Wood shakes are normally installed over a pitched roof on spaced sheathing covered with a vapor barrier. Clay / Concrete Tile - A roof made from different types of clay or thin pieces of concrete made from Portland cement, fine aggregate, and pigments. Clay/Concrete tiles are either tapered or straight and S shaped or barrel shaped with interlocking sidelaps or side joints. Metal (Tin, Steel) - A thin gauge sheet of tin that is typically fastened with an interlocking standing seam system. The seams are either flat or raised. A steel roof consists of corrugated steel sheets applied over a pitched roof. Slate - A dense, fine grained, metamorphic rock produced by the compression of various sediments, cut into thin tiles or slabs. Slate comes in any number of sizes, thicknesses and finishes. Built-Up / Tar Metal Gravel - Three to five layers of roofing felt laminated with coal tar, pitch or asphalt, and topped with a layer of gravel or other aggregate material. Typically found on flat or low-pitched roofs. Additional Features: Bay Window - A set of windows that projects from the wall of a home, forming a bay inside the home. Bow Window - A set of several windows that projects from the wall of a home in the form of an arc. Picture Window - A large framed window, typically 30-40 square feet, made of two layers of glass with a sealed air space between them. A dense, fine grained, metamorphic rock produced by the compression of various sediments, cut into thin tiles or slabs. Slate comes in any number of sizes, thicknesses and finishes.