Replacement Cost Estimate Worksheet
General Information
Name
*
First Name
Last Name
Client Email (A copy of the completed form will be emailed to this address)
*
example@example.com
Who are you working with at ISC? (A copy of the completed form will be sent to them)
*
April Smits
Carrie Baeten
Brenda VanderLogt
Dawn Scullion
Jessica Dellemann
MicKenzie Meissner
Zach Zipperer
NOT SURE
Phone Number
*
-
Area Code
Phone Number
For New Clients: Name of your Current Insurance Company
Address of Property to Insure
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name(s) on Deed:
Number of residents?
Miles to Responding Fire Station:
Is this property within 1,000 feet of a fire hydrant?
Any home claims in 5 years?
Please describe any planned remodeling/renovations:
Property Data
Usage:
Primary
Secondary
Rental
Vacant
Number of Families:
1
2
3
4
Structure Type:
Site Built
Manufactured Home
Mobile Home
Other
Construction Type:
Standard - Typical, builders grade.
Custom - High end materials, features, etc.
Condition of Structure:
Excellent
Good
Fair
Repairs/Updates Needed
Year Built:
Number of Stories:
1 story
1.5 story
2 story
Split Level
Tri-Level
Number of Other Buildings on your Property (Do not include your house)
Number of Bedrooms:
Rows
Number of:
Full Bathrooms (sink, toilet, shower/bath)
Half Bathrooms (sink, toilet)
3/4 Bathrooms (sink, toilet, shower stall)
Square footage of the 1st floor:
Square footage of the 2nd floor:
Square footage of the 3rd floor:
Square footage of Total Living Area excluding the basement:
Square footage of basement:
Basement Type
Rows
Percentage (%)
Poured Walls
Block Walls
Stone Walls
Crawl Space
Slab
Other
What percentage of the basement is finished?
Do you have a walk-out basement?
Yes
No
Do you have a sump pump?
No
Yes, with Battery Backup
Yes, with No Battery Backup
Home Type
A-Frame
Cape Cod
Manufactured Home
Modular Home
Raised Ranch
Ranch
Split Level
Town/Row House
Tri- Level
Two Story
Other
If you picked Other for home type please describe below.
Wall Height - check all that apply.
8ft common typical for pre-2015
9ft common for 2015 and newer
Other
Please describe "other" wall height:
Exterior Walls
Rows
Percent (%)
Clapboard
Wood Siding
Log Siding
Aluminum Siding
Vinyl Siding
Masonry Veneer
Other
Brick (Solid)
Stucco
Log (full log)
Cement Siding
Roof Type
Rows
Percent (%)
Architectural Shingles
Asphalt/Fiberglass Shingles
Wood Shake
Slate
Built-up Tar and Gravel
Rubber
Wood Shingles
Asphalt 3 Tab Shingles
Other
What year was your plumbing last updated?
When your plumbing was updated was it partial or complete?
Partial
Complete
What year was your heating last updated?
When your heating was updated was it partial or complete?
Partial
Complete
Electrical: How many amps are there?
100 amp
200 amp
Other
Electrical: Do you have Fuses or Circuit Breakers?
Fuses
Circuit Breakers
What year was your roof last updated?
*
When your roof was updated was it partial or complete?
Partial
Complete
Structures
Rows
Number of cars
Attached Garage
Built-in Garage
Carport
Detached Garage
Structures
Rows
Square Feet
Open Porch
Closed Porch
Breezway
Balcony
Sun/Seasonal Room
Deck
Other (Describe)
If you have a deck is it made of:
Wood
Composite
Other
Detached Structures
Rows
Description
Dimensions
Replacement Cost
Outbuilding 1
Outbuilding 2
Outbuilding 3
Do you have any of the miscellaneous structures below:
Swimming Pool
Hot Tub
Gazebo/Pergola
Silo
Chicken Coop
Swing Set/Playset
Solar Panels
Other
If you have a swimming pool is it above ground or in ground and does it have any of the following? (Check all that apply)
*
Above Ground
In Ground
Fenced in yard
Lock on pool deck
Diving Board
Slide
NONE
Interior Wall Coverings
Rows
Percent (%)
Paint
Sponge Coat
Vinyl Wallpaper
Ceramic Tile
Marble Tile
Tongue & Groove
Other
Other
Flooring
Rows
Percent (%)
Hardwood
Carpet over Hardwood
Wall to Wall Carpet
Vinyl
Ceramic Tile
Laminated Flooring
Plank
Other
Other
Special Items
Rows
Quantity
Atrium Windows
Picture Windows
Bay Windows
Stain Glass Windows
Skylight
Solar Panels (list value)
Other
Does your Central Air have:
Same Ducts
Separate Ducts
None
What is your Primary Heating Source?
Gas/Propane Furnace
Hot Water Heat
Geothermal
Wood Furnace
Electric Heat
Other
Do you have any of the listed fireplaces:
Fireplace Insert (Converting Wood Fireplace to Gas/Pellet or More Efficient Wood Fireplace)
Gas
Pellet
Wood burning
Do you have a wood or pellet burner in a Detached structure?
Yes
No
Miscellaneous (Check all that apply)
Sprinkler Systems
Central Burglar Alarm
Central Fire Alarm
Smart Home Technology
Deadbolts on all doors
Smoke Detectors
CO Detector
Custom Built Home
High Value Upgrades
Mortgage on House
Farm Land
Hunting Land
Other Land
Oil or Gas Tank
Aluminum Wiring
Water Purification System
Skateboard Ramp/Zip Line
Trampoline
Wet Bar
Cigarette Smoker in Home
Roomers/Boarders
How many acres of Farm Land do you have?
How many acres of Hunting Land do you have?
How many acres of Other Land do you have?
Do you conduct any business on property (farming, business, hobby for money, daycare, etc)
*
Yes
No
Please describe the business conducted:
Do you have any animals?
Yes
No
If you have animals please list the types and breeds:
For Dogs, do they have any bite history?
Yes
No
Please describe any additional features that may impact the rebuilding costs:
For New Purchase
What is the Purchase Price of the house?
When is the Closing Date?
Will you be moving into this home within 30 days of purchase?
What is the Mortgagee Clause?
What is the Loan Number?
Do you have Escrow for Insurance Premiums?
Yes, the escrow company will pay my premiums.
No, I pay premiums.
For Homes Under Construction
When is the Estimated Completion Date?
What is the Name of the Contractor?
What is the Mortgagee Clause?
What is the Loan Number?
Do you have Escrow for Insurance Premiums?
Yes, the escrow company will pay my premiums.
No, I pay premiums.
Please list any other questions, comments, or concerns:
Signature (On mobile device, use finger or stylus, on a computer/laptop, use your mouse)
*
For Office Use Only
Send ISC Copy to:
example@example.com
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