Replacement Cost Questionnaire 1. Please provide some general information about yourself: A) Name and address of insured location (as it appears on your Homeowners policy): Name: Street Address: City: State: Zip Code: B) Daytime Phone Number: Evening Phone Number: C) Homeowners Policy Number: D) What is the current market value (appraised value)* of your home? * The market value (appraised value) is the price the home could be sold for on the real estate market, including the land. E) If you are refinancing, what is your loan amount? F) What Coverage A amount are you requesting? 2. Please provide some general information about your home: My home is a 1, 2, or 3 family home. (Circle one) My home was built in (Year) How many stories is your home from the ground level up? (Check one X) (1) (1 1/2) (2) (2 1/2) (3) 3. The style that most closely resembles my home is: (Check one X) Style X Style X Style X Ranch Bi-level Row House - End Queen Anne Back Split Row House - Center Cape Cod Raised Ranch Town House - End Colonial Split Foyer Town House - Center Contemporary Split Level Victorian Federal Colonial Tri-Level Other (Describe) 4. Please enter the total square footage of your home: square feet. (Do not include the basement, porches, breezeways, decks, or one story attached garages. Please include built in garages, which have living areas above them.) Only If the total square footage is unknown, please complete the room count section in the chart on the following page. Please enter the quantity of rooms in your home by type and size. Enter "1" for each room type in your home. For example, if there are two small bedrooms in your home, you would list the number "2" in the small bedroom box in the chart on the next page. Use the size chart below as a guide. Room Size Living & Family Room Dining Room, Breakfast Nook, & Den Kitchen Bedroom Small: 15 x 15 10 x 10 12 x 12 12 x 12 Medium: 15 x 20 10 x 12 12 x 15 15 x 12 Large: 20 x 20 12 x 15 15 x 15 15 x 15 PCD 4077 Ed. 5/03 Page 1 of 6
ROOM COUNT Room Name Small Medium Large Living Rooms Dining Rooms Kitchens Breakfast Nooks Den/Study/Offices Family Rooms Bedrooms Entries/Foyers Mud Rooms Laundry/Utility/Sewing Storage Rooms Full Baths Half Baths Extra Rooms Built-in Garage 5. Of the ENTIRE FIRST FLOOR of your home, what percentage of the total first floor has a basement, crawl space, or concrete slab under it? % Concrete Slab: % Crawl Space: % Basement: If the home has a basement, what percentage of the area is finished? % 6. Please provide some general information about the construction materials used for your home. A) The exterior walls of my home can best be described as being constructed of (list the percentage that applies for each type used): Exterior Walls Aluminum Siding Vinyl Siding Wood Siding Wood Shakes Logs Logs - Custom Cedar Stucco on Frame Stucco on Block Brick Veneer Brick and Block Solid Brick Stone Veneer Stone and Block Solid Stone Block (Painted) Poured Concrete Other (Describe) B) The roof of my home is best described as being constructed of (Please list the percentage that applies for each type used): Roofing Asphalt / Fiberglass Shingle Wood Shake Slate Built-up Tar and Gravel Copper Wood Shingles Fiberglass Panel Other (Describe) Page 2 of 6
C) The following best describes the garage in my home: 1. I do not have a garage. 2. I have a carport, attached to my home. 3. I have a garage/carport, but it is NOT attached to my home. 4. I have a garage, attached/built-in to my home Please enter the quantity of the type of garage in your home. For example, if there is a 2 car garage attached to your home, you would list the number 1 in the "Attached Garage - 2 Car" box. Garage Definitions: An attached garage is directly attached to the house and does not have any living area above it. A built-in garage is built into the residence at the first floor or grade level, which has living area above and which has been included in the dimensions/floor area of the house (the way it would be in a split-level or bi-level home. A carport is a flat-roofed or gable-roofed shelter supported by vertical posts, generally attached to the residence on one side. Garages Quantity Garages Quantity Attached Garage - 1 Car Built-in Garage - 3 Car Attached Garage - 1.5 Car Built-in Garage - 3.5 Car Attached Garage - 2 Car Basement Garage - 1 Car Attached Garage - 2.5 Car Basement Garage - 1.5 Car Attached Garage - 3 Car Basement Garage - 2 Car Attached Garage - 3.5 Car Basement Garage - 2.5 Car Attached Barn Basement Garage - 3 Car Built-in Garage - 1 Car Carport - 1 Car Built-in Garage - 1.5 Car Carport - 2 Car Built-in Garage - 2 Car Carport - 3 Car Built-in Garage - 2.5 Car D) The following best describes the attached structures of my home (Please enter the quantity, square feet, or dimensions of the structure): Attached Structures Open Porch Small Open Porch Medium Open Porch Large Open Porch - Square Feet Screened Porch Small Screened Porch Medium Screened Porch Large Screened Porch - Square Feet Screened Pool Enclosure - Square Feet Closed Porch Small Closed Porch Medium Closed Porch Large Closed Porch - Square Feet Open Breezeway Small Open Breezeway Medium Open Breezeway Large Open Breezeway - Square Feet Screened Breezeway - Small Screened Breezeway - Medium Screened Breezeway - Large Screened Breezeway - Square Feet Closed Breezeway - Small Closed Breezeway - Medium Closed Breezeway - Large Closed Breezeway - Square Feet Wood Deck - Small Attached Structures Wood Deck - Medium Wood Deck - Large Wood Deck - Square Feet Redwood Deck - Small Redwood Deck - Medium Redwood Deck - Large Redwood Deck - Square Feet Composite Deck - (Sq. Ft.) Patio Cover - Small Patio Cover - Medium Patio Cover - Large Patio Cover - Square Feet Solar Room - Small Solar Room - Medium Solar Room - Large Solar Room - Square Feet Greenhouse - Small Greenhouse - Medium Greenhouse - Large Greenhouse - Square Feet Balcony - Small Balcony - Medium Balcony - Large Balcony - Square Feet Indoor Pool Hot Tub Page 3 of 6
E) The following best describes the exterior detached structures of my home (Please enter the quantity, square feet, or dimensions of the structure): Detached Structures Detached Garage - 1 Car Detached Garage - 1.5 Car Detached Garage - 2 Car Detached Garage - 2.5 Car Detached Garage - 3 Car Detached Garage - 3.5 Car Shed Small Shed - Medium Shed Large Swimming Pool - Fiberglass Detached Structures Swimming Pool - Concrete (Small) Swimming Pool - Concrete (Medium) Swimming Pool - Concrete (Large) Swimming Pool - Concrete (Extra Lg.) Screened Pool Enclosure Stable Gazebo Barbeque Hot Tub F) The following best describes the special items in my home (Please enter the quantity of the special items): Special Items Quantity (1, 2, 3 ) Special Items Quantity (1, 2, 3 ) Atrium Windows Atrium Doors Picture Windows Sliding Glass Doors Bay Windows Skylight - Small (4x4) Bow Windows Skylight - Large (6x6) Greenhouse Windows Solar Panels Stain Glass Windows - Small (3x5) Special Items Square Feet Stain Glass Windows - Large (5x7) Skirting * * Skirting is a covering surrounding the open foundation area of a home. Enter the total square footage of skirting. G) The interior walls of my home are best described as being constructed of (Please list the percentage that applies for each type used): Interior Walls/Partitions Drywall Drywall - Textured Plaster Plaster - Textured Block Interior Walls/Partitions Brick and Block Stone and Block Solid Brick Solid Stone H) The interior walls of my home are COVERED with (Please list the percentage that applies for each type used): Wall Coverings Paint Sponge Coat Marble Paint Vinyl Wallpaper Foil Wallpaper Grass Cloth Paper Ceramic Tile Imported Ceramic Tile Marble Tile Sheet Paneling Wall Coverings Solid Wood Paneling Tongue & Groove Millwork Bookcase Walls Knotty Pine Mirrors Brick Facing Stone Facing Terrazzo I) The ceilings in my home are constructed of the following (Please list the percentage that applies for each type used): Ceilings Drywall Drywall - Textured Plaster Plaster - Textured Acoustical Spray Acoustical Texture Ceilings Wood Tongue & Groove Mirrors Stucco Finish Recessed Lighting Page 4 of 6
J) The floor covering in my home consists of the following (Please list the percentage that applies for each type used): Flooring Hardwood Carpet over Hardwood (Acrylic/Nylon) Carpet over Hardwood (Custom Acrylic) Carpet over Hardwood (Wool/Berber) Wall to Wall Carpet (Acrylic/Nylon) Wall to Wall Carpet (Custom Acrylic) Wall to Wall Carpet (Wool/Berber) Vinyl Ceramic Tile Ceramic Tile - Imported Parquet Flooring Plank Plywood Only Marble Tile Mural Tile Flagstone Brick Slate Terrazzo Tile Stone Granite Cork Flooring K) My home has the following interior items (Please enter the quantity of the interior items): Kitchen and Bath Definitions: Kitchen - Basic: A kitchen that typically includes base and wall cabinets, paint-grade wood or vinyl veneer countertops, standard grade laminated plastic, 1 built-in range/oven, 1 built-in dishwasher, 1 sink with faucet, 1 garbage disposal, and 1 range hood with two-speed exhaust fan, outlet duct, and light. Kitchen - Builder's Grade: A kitchen that typically includes base and wall cabinets, prefinished plywood or equivalent - countertops, good grade laminated plastic or ceramic tile, 1 built-in range/oven, 1 built-in dishwasher, 1 sink and faucet, 1 garbage disposal, and 1 range hood with two-speed exhaust fan, outlet duct, and light. Kitchen - Custom: A kitchen that typically includes base and wall cabinets, custom, wood countertops and splash, ceramic tile, simulated marble or high-end laminated plastic, 1 custom wood island cabinet, 1 ceramic tile, simulated marble or high-end laminated plastic island countertop, 1 custom wood pantry, 1 wall oven, 1 cooktop, 1 custom range hood, 1 built-in dishwasher, 1 garbage disposal, 1 Subzero type refrigerator, 1 sink and faucet, 1 island sink and faucet, 1 drinking water filter, and 1 instant hot water dispenser. Kitchen - Designer: A kitchen that typically includes base and wall cabinets, custom, high-end wood countertops and splash (marble, granite, high-end ceramic tile), 1 custom, high-end wood peninsula cabinet, 1 maple or same as countertops peninsula countertop, 1 motorized pantry, 1 double oven, 1 built-in microwave oven, 1 cooktop, 1 indoor BBQ, 1 vented copper or stainless steel range hood, 1 built-in dishwasher, 1 garbage disposal, 1 built-in trash compactor, 1 Subzero type refrigerator, 1 sink and faucet, 1 peninsula sink and faucet, 1 drinking water filter, 1 instant hot water dispenser, and under cabinet lighting. Full Bath: A bathroom with 3 or more fixtures: sink, toilet, tub. Half Bath: A bathroom with 2 fixtures: sink, toilet. Three-Quarter Bath: A bathroom with three fixtures, one being a shower stall, and no tub. Interior Items Quantity (1, 2, 3 ) Interior Items Quantity (1, 2, 3 ) Kitchen - Basic Fireplace - Single Kitchen - Builder's Grade Fireplace - Double Kitchen - Custom Fireplace - Triple Kitchen - Designer Wood Stove - Free Standing Full Bath - Basic Fireplace - 0 Clearance Insert Full Bath - Builder's Grade Gas Fireplace Full Bath - Custom Direct Vent Fireplace Full Bath - Designer Kiva Half Bath - Basic French Doors (count each door) Half Bath - Builder's Grade Hot Tub Half Bath - Custom Jacuzzi Half Bath - Designer Wet Bar Three Quarter Bath - Basic Vanity - Custom Installed Three Quarter Bath - Builder's Grade Metal Spiral Staircase Three Quarter Bath - Custom Wood Spiral Staircase Three Quarter Bath - Designer Finished Attic Page 5 of 6
L) What type of heating and cooling system do you have in your home? For example, if your entire home is heated and cooled by central heat and central air conditioning, you would list 100% in the "Heat and Central Air Conditioning" box. Heating and/or Cooling Heating and/or Cooling System System Heating System Heating - Oil Hot Water with Radiators Central Air Conditioning Heating - Propane Gas Hot Air Heat & Central Air Heating - Propane Gas Hot Water Conditioning Heating - Electric Radiant Floor Heating System Heating - Gas Central Air Conditioning - Same Ducts Heating - Oil Central Air Conditioning - Separate Ducts Heating - Gas Hot Air Heating and/or Cooling System Quantity (1, 2, 3 ) Heating - Gas Hot Water Electric Heat Pump Heating - Oil Hot Air Additional Furnace Heating - Oil Hot Water Whole House Fan (attic fan) M) What percentage of the total home do the following devices cover? Miscellaneous Systems Interior Sprinkler Systems Central Burglar Alarm System Central Vacuum System Intercom System Central Fire Alarm System Central Stereo System Page 6 of 6