Home Evaluation Questionnaire Name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone1. What Year Was Your Home Built?2. 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 MaterialsExact Replica Materials3. Which Type of Home Do You Have?One familyTwo familyThree familyFour family4. Please Check Which Picture Most Resembles Your HomeOne StoryTwo Story/Three StoryVictorianSplit- Level/Tri-LevelBi-Level/Two Levels1.5 StoryAdobeTownhome-End UnitTownhome-Middle UnitContemporaryDo You Have a Garage or Carport?YesNoTotal Living Area, Excluding basement and atticFoundation Type (Must add up to 100%): Basement %Crawl Space %Slab %Do you have a basement?YesNoIs your basement a walkout?YesNoWhat percentage of your basement is finished? %If finished, finish styleStandardCustomDo You Have AWood deckComposite deckPorchNoneIs your porch...EnclosedScreenedOpenWhat is the square foot of your deck/porch?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, total should be 100%:Exterior Walls (should add up to 100%):Brick (solid) %Brick Veneer/Brick on Frame %Concrete Block %Stone (Solid) %Stone Veneer/Stone on Frame %Stucco on Block %Stucco on Frame %Wood Siding/Shakes %Vinyl/Aluminum Siding %Other: Please Specify and include %Floor Finishes (should add up to 100%):Hardwood %Carpet %Carpet over Hardwood %Ceramic Tile %Clay Tile %Marble/Granite/Solid %Slate/Brick/Flagstone %Vinyl %Other: Please Specify and include %Please select the primary roofing material on your homeAsphalt Shingles Wood Shingles Clay/Concrete Tile Metal(Tin, Steel)SlateBuilt-up Tar/GravelOtherIf "other", please specifyHow many kitchens are in your home?Please indicate if any of your kitchens have the following special features (check all that apply) Corian, Granite, or Marble Countertops Center Island with Cabinents or Sink 6 or more total range top burners More than one oven Commercial Style Refrigerator How many bathrooms are in your home?Please check all that apply Full (tub/shower, sink & toilet) Corian, Granite or Marble Third Choice Double Sink Half (sink & toilet): Spa or Jacuzzi Tub Bathtub and separate shower stall Please indicate the number of these additional features in your homeWindowsBay WindowsBow WindowsPicture WindowsDoors & FireplacesAtrium/French DoorsSliding Glass DoorsFireplacePlease 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?