Replacement Cost Form Intake v2 Named Insured(Required) First Last Date of Birth(Required) Month Day Year Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Agent Full Name Housing InformationPolicy Type Renewal New Purchase Year Built Type of Home One Family Two Family Three Family Four Family For Home 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 (Ex: Drywall, Standard Wood, Concrete Foundation, 8 Foot Ceiling) Exact Replica Materials (Ex: Plaster Walls, 10 Foot Ceilings, Rough Lumber) Number of Stories Square Footage Number of Garage Spaces 1 2 3 4 5+ Garage Type Attached Detached Basement Garage Carport No Garage Number of Cars Number of Bathrooms 1 1.5 2.5 3 3.5 4 4.5 5+ Number of Bedrooms 1 2 3 4 5+ If you have a basement: Is it a walkout? Yes No I do not have a basement Number of Kitchens Kitchen Total Sq.ft Please indicate if any of your kitchens have the following special feaures: Corian, Granite or Authentic Marble Counter Tops More Than One Oven Center Island with Cabinets or Sink Commercial Style Refrigerator (E.g. Sub-Zero Style) 6 or More Total Range Top Burners Exterior Wall Material Brick (Solid) Brick Veneer / Brick on Frame Concrete Block Stone (Solid) Stone Veneer / Stone on Frame Stucco on Frame Wood Siding / Shakes Vinyl / Aluminum Siding Other Select all that apply. Floor Finishes Hardwood Carpet Carpet over Hardwood Ceramic Tile Clay Tile Marble / Granite / Solid Stone Slate / Brick / Flagstone Vinyl Other Select all that apply. Roofing Material Shingles Asphalt / Composition Wood Shingles Shakes Clay / Concrete Tile Metal (Tin, Steel) Slate Built-Up / Tar & Gravel Other Select all that apply.Year Roof Updated Year Electrical Updated Year Plumbing Updated Year HVAC Updated Do you have a:Wood Deck:Composite Deck:Porch: Add RemovePlease type the Total Sq.ft for all that applyAny additional window features in your home? Skylights Bay Windows Bow Windows Picture Windows Any additional doors/fireplace features in your home? Atrium/French Doors Sliding Glass Doors Fireplace 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? Primary Source of Heat Oil Gas Electric Other Do you have an active alarm system? Yes No Do you have dogs? Yes No Is there a sump pump? Yes No Does you home have a: Pool Hot Tub Trampoline Consent(Required) I agree to the privacy policy.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:(Required) Type your full name
