Fillable Printable Home Replacement Cost Evaluation Form

Home Replacement Cost Evaluation Form

(For use with Marshall & Swift / Boeckh RCT Express Replacement Cost Program)

Insured/Applicant Name: ______________________________________________________________________

Address: __________________________________________________________________________________

Agency / Code: ______________________________ Completed By: __________________________________

1. What year was your home built? _______________ Type? 1 – Family___ 2 – Family___ 3 – Family___

2. What style is your home? 1 Story__ 1.5 Story__ 2 Story__ 2.5 Story__ Bi-Level__ Split Level__Other____________

3. What is the total square footage of the finished living area of your home? ____________________ Square Feet

4. Does your home have a: Deck (Sq. Ft.: ________) Cathedral Ce ilings (% of home: __________%)

Breezeway (Sq. Ft.: __________) Is Breezeway: Enclosed_____ Screened___ Open_____

Porch (Sq. Ft: ____________) Is Porch: Enclosed_____ Screened_____ Open_____

5. Which of the following additional features are in your home?

Skylights: #______ Picture Window: #_____ Atrium/French Door: #___ Central Alarm: %_______

Bay Windows: #______ Glass Sliding Door: #____ Woodstove: #______ Hot Tub: Sq Ft _______

Bow Windows: #______ Atrium Window: #______ Greenhouse: Sq Ft ______ Wet Bar: #_______

6. Do you have a garage? No___ Yes___ Attached___ Built-in___ Carport___ Detached___

How many vehicles can be parked in the garage? One Car___ Two Cars___ Three Cars___ Four Cars___

7. Does your home have a basement? No Yes If YES, percentage finished: __________%

8. If your home does not have a full basement, what percentage is: Slab: _____% Crawl Space: _____% Stilts: _____%

9. Which materials listed below best describe the materials found in your home? Please indicate the materials as

percentages of total (e.g. 5%, 10%, 15 %, etc). If your hom e contains material not f ound on the list, please select a similar

material that is in the list and use the reverse side of this form for additional explanation, if necessary. Your selection

should total 100% in each category.

EXTERIOR WALLS

INTERIOR WALLS ROOF COVER FLOOR FINISHES

Clapboard: _______ Plaster: _______ Asphalt: _______ Hardwood: _______

Wood Siding: _______ Dry Wall: _______ Metal: _______ W to W Carpet: ________

Aluminum Siding: _______ Studs Only: _______ Slate: _______ W to W over Hardwood: ____

Vinyl Siding: _______

WALL FINISHES

Clay Tile: _______ Wool/Berber Carpet: ______

Wood Shakes: _______ Paint: _______ Wood Shakes: _______ Parquet: _______

Brick Veneer: _______ Faux Finish: _______ Tar & Gravel: _______ Ceramic Tile: _______

Stone Veneer: _______ Wallpaper: _______ Rubber: _______ Marble Tile: _______

Stucco: _______ Paneling: _______

CEILINGS

Slate: _______

Block: ________ Ceramic Tile: _______ Drywall: _______ Brick: _______

Solid Brick: _______ Brick: ______ Plaster: _______

Solid Stone: _______ Stone: _______ Acoustic Tile: _______

Masonry: _______ Marble: _______ Wood: _______

Log: _______ Knotty Pine: _______ Other: __________________

T-111: ______

10. How many kitchens are in your home? __________

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

Corian, Granite, or authentic marble countertop____ Jenn-Aire Stove____ Sub-Zero Refrigerator____

Center Island w/ Cabinets or si nk____ Walk-in Freezer___ Motorized Pantry___ Indoor BBQ___

11. Please indicate the number of bathrooms that are:

_____ Full (3 or more fixtures w/tub) ______ Half (Sink, toilet, stand up shower) _____Half (Sink/toilet only)

Please indicate quality grade: Standard___ Custom___ Designer___

12. What is your homes primary source of heat? Oil___ Gas___ Electric___ Other: ___________________________

If you heat with oil, where is the storage tank located: Basement___ Outside - Above Ground___ Garage___

Outside – Underground___ Other: ___________________

Do you have a secondary source of heat? No____ Yes____ (please describe):__________________ _________ ____ _

13. Does your home have central air conditioning? No____ Yes____ – shared ducts with heating system? Yes___ No___

14. Does your home have a central vacuum system? No____ Yes____

15. How many fireplaces with masonry chimneys? None Single (#___) Double (#___) Triple (#___)

(DOUBLE is two fireboxes and one chimney, TRIPLE is three fireboxes and one chimney)

DIAGRAM SECTION

In the space below, please provide a basic, top view diagram of your home (with dimensions, if known).