Insurance Service Center DePere - Replacement Cost Estimator

Client Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What year was your home built?

Years owned?

Name of Responding Fire Dept:

Miles to Fire Department:

Is your home within 1000 feet from a fire hydrant?

Township:

County:

Number of Stories

Ground floor area: (in square feet)

Total square feet: (do not include basement)

Construction type:

Roof type

Exterior type (i.e. vinyl)

Size of lot/acreage

Basement:

How many square feet is your basement?

Is basement finished?

If yes, what percentage of your basement is finished?

Is it a walk-out basement?

How many amps of electrical?

Other:

Does home have any fuses?

Do you have a wood/pellet/coal stove or burner in any structure?

(if yes, describe)

Does you have any animals/pets?

(if yes, describe)

Any home claims in the last 5 years?

(if yes, please explain)

What is the approximate age of:

Roof

Plumbing

Electrical

Furnace

Do you have a garage?

How many stalls?

Other

Is it attached to your home?

If not attached, what amount do want to insure it for?

Do you have any other buildings (silos, gazebos, sheds)?

If yes, list type of buildings & size?

If you have a deck, how many square feet is it?

If you have a porch, how many square feet is it?

If yes, is it open or enclosed?

Number of Bathrooms:

Full Bath (sink, toilet, shower/bath)

Half Bath (sink, toilet)

3/4

Fireplace: (select all that apply)

Gas Fireplace

(if yes, how many chimneys?)

Wood Fireplace

(if yes, how many chimneys?)

Is your home a single family residence?

(if no, how many families?)

Do you have any of the following (check all that apply):

Physical condition:

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