REPLACEMENT COST ESTIMATOR FORM

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Josephine Collins
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1 REPLACEMENT COST ESTIMATOR FORM GENERAL INFORMATION Policy Number: Current Coverage: Insured Name: Property Address: Property Zip: Davis, Clark & Latham Ins. Agency 1 Pleasant Street, Suite 3 Reading, MA Phone: Fax: PROPERTY DATA Usage: Primary Secondary Rental Vacant Number of Families: IMPORTANT - Total Living Area (in Sq. Ft.) Main Section Wing 1 Wing 2 Ranch Bi-Level Cape Cod Colonial Contemporary Raised Ranch Split Level Tri-Level Town/Row House - Center Unit Town/Row House - End Unit Bi-Level/Row - Center Unit Bi-Level/Row - End Unit Tri-Level/Row - Center Unit Tri-Level/Row - End Unit Victorian Ornate Victorian Other: Main Section Total Living Area: sq. ft. Main Section additional 1 Story 1 1/2 Story 2 Story 2 1/2 Story 3 Story Wing 1 Total Living Area: sq. ft. Wing 1 additional Access Flat Area / Easy Access Roads Slightly Congested Roads Narrow Roads / Hillside Area Difficult Access / Steep Terrain Island Access - Short Distance Island Access - Long Distance Elevator Access Isolated Rural Area Mountain Access 1 Story 1 1/2 Story 2 Story 2 1/2 Story 3 Story Wing 2 Total Living Area: sq. ft. Wing 2 additional NOTE: Do not include square footage of finished basement in calculating Total Living Area. NOTE: If Hillside Foundation is selected, you must specify both the slope and access. See the following page for your choices. Revised 10/2005

2 Slope 0 to 15 Degrees 15 to 30 Degrees 30 to 45 Degrees More than 45 Degrees Special Conditions Square Shape Rectangular Shape Irregular Shape Very Irregular Shape Elaborate Roof EXTERIOR Exterior Walls % Roofing % Clapboard Clapboard - Redwood Wood Siding Wood Shakes T1-11 Siding New England Shingle Victorian Scalloped Shakes Log Siding Aluminum Siding Vinyl Siding Brick Veneer Brick and Block Solid Brownstone Cement Fiber Shingles Hardboard Siding Other (Describe) Architectural Shingles Asphalt / Fiberglass Shingles Wood Shake Slate Built-up Tar and Gravel Rubber Wood Shingles Other (Describe) Year roofing last updated: Electrical Heating Amperage of Service: Amps Fuses Circuit Breakers Year wiring last updated: Year heating last updated: Plumbing Year plumbing last updated: Attached Structures Qty. Attached Structures Sq. Ft. Attached Garage (no. of cars) Built-in Garage (no. of cars) Carport (no. of cars) Solar Room (dimensions) Greenhouse (dimensions) Hot Tub Other (describe) Open Porch Screened Porch Closed Porch Open Breezeway Screened Breezeway Closed Breezeway Deck (type of material) Solar Room Greenhouse Balcony: small medium large Screen Pool Enclosure Other (describe) 2

Block Solid Brownstone Cement Fiber Shingles Hardboard Siding Other (Describe) Architectural Shingles Asphalt / Fiberglass Shingles Wood Shake Slate Built-up Tar and Gravel Rubber Wood Shingles Other

3 EXTERIOR continued Special Items Qty. Detached Structures Qty. Atrium Windows Picture Windows Bay Windows Bow Windows Greenhouse Windows Stain Glass Windows - small Stain Glass Windows - large Exterior Storm Shutters Atrium Doors Sliding Glass Doors Skylight - small Skylight - large Solar Panels Detached Garage (no. of cars) Detached Garage with Finished Area (no. of cars) Shed (size) Swimming Pool size: material: Other (describe) INTERIOR Partitions % Ceilings % Drywall Drywall - Textured Plaster Plaster - Textured Studs Only Plywood Only Other (describe) Wall Coverings % Paint Sponge Coat Vinyl Wallpaper Ceramic Tile Imported Ceramic Tile Marble Tile Sheet Paneling Solid Wood Paneling Tongue & Groove Knotty Pine Other (describe) Miscellaneous Systems Interior Sprinkler Systems Central Burglar Alarm System Central Vacuum System Intercom System Central Fire Alarm System Central Stereo System Deadbolt (qty.) Fire Extinguisher (qty.) Smoke Detector (qty.) CO Detector (qty.) % or Qty. Drywall Drywall - Textured Plaster Plaster - Textured Plaster - Horsehair Acoustical Spray Acoustical Texture Wood Tongue & Groove Stucco Finish Recessed Lighting Other (describe) 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) Vinyl Ceramic Tile Ceramic Tile - Imported Laminated Flooring Parquet Plank Marble Tile Other (describe) Interior Items Sq. Ft. Finished Attic

small Skylight - large Solar Panels Detached Garage (no. of cars) Detached Garage with Finished Area (no.

4 INTERIOR continued Interior Items Qty. HVAC % Kitchen - Basic Kitchen - Builder s Grade Kitchen - Semi-Custom Kitchen - Custom Kitchen - Designer Full Bath - Basic Full Bath - Builder s Grade Full Bath - Semi-Custom Full Bath - Custom Full Bath - Designer Half Bath - Basic Half Bath - Builder s Grade Half Bath - Semi-Custom Half Bath - Custom Half Bath - Designer Three Quarter Bath - Basic Three Quarter Bath - Builder s Grade Three Quarter Bath - Semi-Custom Three Quarter Bath - Custom Three Quarter Bath - Designer Fireplace - Single Fireplace - Double Fireplace - Triple Wood Stove - Free Standing Fireplace - Zero Clearance Insert Gas Fireplace Direct Vent Fireplace Kiva French Doors (count each door) Hot Tub Jacuzzi Wet Bar Vanity - Custom Installed Metal Spiral Staircase Wood Spiral Staircase Heating - Electric Heating - Gas Heating - Gas Hot Air Heating - Gas Hot Water Heating - Oil Heating - Oil Hot Air Heating - Oil Hot Water Heating - Oil Hot Water w/ Radiators Location of Oil Tank: Heating - Propane Gas Hot Air Heating - Propane Gas Hot Water Radiant Floor Heating System Central Air Conditioning - Same Ducts Central Air Cond. - Separate Ducts Whole House Fan HVAC Electric Heat Pump Evaporative Coolers Evaporative Coolers, Window Units Additional Furnace Qty. NOTE: Do not include small window air conditioning units MISCELLANEOUS Write-In Components % Write-In Components Qty. 4

Full Bath - Designer Half Bath - Basic Half Bath - Builder s Grade Half Bath - Semi-Custom Half Bath - Custom Half Bath - Designer Three Quarter Bath - Basic Three Quarter Bath - Builder s Grade

5 GENERAL QUESTIONS Anyone in home a smoker? Do you have any pets? If yes, how many & what type? If Dog, what breed(s)? Do you have a trampoline? Any losses in the last three years? If Yes, explain Do you do any work from home? Do you have any plumbing fixtures or appliances that are below grade? Yes No Yes No How many Type: _ Breed(s): Yes No Yes No Yes No Yes No If coastal town, what is the distance to the ocean Are you interested in coverage for any of the following excluded perils? Earthquake: Ground Water (sump pump coverage): Flood: Business on your property: Personal Umbrella Liability policy: Yes No Yes No Yes No Yes No Yes No The following are covered on a limited basis Are you interested in learning more about additional coverage for any of the items listed below? If yes, which ones? Antiques Fine Arts Jewelry Watercraft Collectibles Fire Arms Silverware Signature Date Owner #1 - Social Security # Owner #2 - Social Security # Date of Birth Date of Birth Home phone number: Work phone number: Cell phone number: address:

Yes No Yes No How many Type: _ Breed(s): Yes No Yes No Yes No Yes No If coastal town, what is the distance to the ocean Are you interested in coverage for any of the following excluded perils?

2. Complete the appropriate sections of the Auto/Home Quote form. 4. Return all materials to Paul Goebel Group. or your local Citizens Agent.

Instructions 1. Print off all necessary forms 2. Complete the appropriate sections of the Auto/Home Quote form. If you have any questions while completing this form please call Alice at 1-800-632-4591.