Independent Insurance Agency | Stanton Insurance | Waltham, …



Name: __________________________________________________________________________________________________________

Address (including zip code): ______________________________________________________________________________

1. What year was your home built? __________ # of Families? __________

2. Style? (circle one)

1 story 1.5 Story 2 Story 2.5 Story 3 Story Ranch Cape Cod Colonial

Bungalow Victorian Town House Bi-Level Split Level Raised Ranch Contemporary

3. What is the Total Living Area (TLA) (Square Footage)? __________ (footprints times the # of stories)

4. If unable to provide total living area please provide the number of rooms in the home:

_____ Kitchen _____ Bedrooms (more than 150 sq ft) _____ Utility/Laundry/Sewing _____ Living Room

_____ Dining Room _____ Bedrooms (less than 150 sq ft) _____ Family/Rec Room _____ Entry/Foyer

_____ Full Bath _____ Half Bath _____ Great Room _____ Den/Study/Office

_____ Storage (other than basement) _____ Walk In Closets _____ Other

• Are any of these rooms over 225 square feet?  Yes  No If yes, how many? __________

5. Do you have a basement?  Yes  No

• If yes, what percentage of the first floor has a basement under it? _____ % What percentage of the basement is finished?_____ %

• What percentage of the first floor is built on a slab or crawl space? _____ % Slab _____ % Crawl Space

6. Is the house on a pier or stilts?  Yes  No

7. Exterior Information

Exterior Walls (indicate % of each to total)

_____ Clapboard _____ Wood Siding _____ Wood Shakes _____ Aluminum Siding

_____ Vinyl Siding _____ Stucco/Frame _____ Brick Veneer _____ Stone Veneer

_____ Solid Stone _____ Block _____ Other (explain) _____________________________

Roofing (indicate % of each to total)

_____ Asphalt/Fiberglass Shingle _____ Wood Shake _____ Slate _____ Built Up/Tar & Gravel _____ Rubber

_____ Concrete Tile _____ Clay Tile _____ Spanish Tile _____ Tin _____ Copper

_____ New England Pine Shingle _____ Wood Shingles _____ Steel Roofing _____ Victorian Scalloped Shake

_____ Fiberglass Panel _____ Plexiglas Roofing _____ Other (explain) ______________________________________

Attached Structures (indicate # and square footage where appropriate)

_____ Attached Garage (# of cars _____) _____ Built-In Garage (# of cars _____) _____ Carport (# of cars _____ )

_____ Open Porch (sq ft _____ ) _____ Screen Porch (sq ft _____ ) _____ Closed Porch (sq ft _____ )

_____ Screened Breezeway (sq ft _____) _____ Closed Breezeway (sq ft _____) _____Wood Deck (sq ft _____)

_____ Redwood Deck (sq ft _____) _____ Greenhouse (sq ft _____) _____ Other (explain) ____________________________

Detached Structures (indicate # and square footage where appropriate)

_____ Garage ( # of cars _____) _____ Shed ( sq ft _____) _____ Hot Tub

_____ Above Ground Swimming Pool _____ In Ground Swimming Pool _____ Other (explain) ____________________________

Special Items (indicate # and square footage where appropriate)

_____ Atrium Windows (#) _____Picture Windows (#) _____ Bay Windows (#) _____ Bow Windows (#)

_____ Stained Glass Windows (small 3x5) (#) _____ Exterior Storm Shutters (#) _____ Solar Panels (#) _____ Atrium Doors (#)

_____ Stained Glass Windows (large 5x7) (#) _____ Sliding Glass Doors (#) _____ Skirting (Hillside) (Sq Ft _____)

_____ Skylights (small 4x4 ) (#) _____ Skylights (large 6x6) (#) _____ Other (explain) __________________________

8. Interior Information

Partitions (indicate % of each to total)

_____ Drywall _____Textured Drywall _____ Plaster _____ Textured Plaster _____ Horsehair Plaster

_____ Studs Only _____ Plywood Only _____ Block _____ Brick & Block _____ Stone & Brick

_____ Adobe _____ Solid Brick _____ Solid Stone _____ Other (explain) __________________________

Wall Coverings (indicate % of each to total)

_____ Paint _____Vinyl Wallpaper _____ Foil Wallpaper _____ Grass Cloth Paper _____ Ceramic Tile

_____ Imported Tile _____ Sheet Paneling _____ Soling Wood Paneling _____ Tongue & Groove _____ Millwork

_____ Knotty Pine _____ Bookcase Walls _____ Mirrors _____ Other (explain) __________________________

Ceilings (indicate % of each to total)

_____ Drywall _____Textured Drywall _____ Plaster _____ Textured Plaster _____ Tin

_____ Acoustical _____ Wood _____ Millwork _____ Tongue & Groove _____ Mirrors

_____ Other (explain) __________________________

Flooring (indicate % of each to total)

_____ Hardwood _____ Vinyl _____ Ceramic Tile _____ Parquet _____ Marble Tile _____ Plank

_____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 (Wool/Berber) _____ Wall to Wall Carpet (Custom/Acrylic/Nylon)

_____ Other (explain) __________________________

Interior (indicate #)

_____ Fireplace (single) _____ Fireplace (double) _____ Fireplace (triple) _____ Hot Tub _____ Jacuzzi

_____ Wood Stove (Free Standing) _____ Wood Stove (Zero Clearance Insert) _____ French Doors _____ Elevator _____ Wet Bar

_____ Custom Installed Vanity _____ Other (explain) __________________________

How Many Kitchens? _____ Please indicate if any of the kitchens have the following special features

_____Corian, Granite, or Authentic Marble Countertops _____ Center Island Unit with Cabinets or sink _____ Jenn-Aire Stove

_____ Commercial-Style Refrigerator, ex Sub-Zero _____ Motorized Pantry _____ Other (explain) __________________________

Bathrooms (Indicate # and type of all bathrooms in the house)

_____ Full (tub/shower, sink, toilet) _____ Half (sink, toilet)

Please indicate if any of the bathrooms have the following special features

_____Corian, Granite, or Authentic Marble _____ Double Sink & Vanity _____ Spa or Jacuzzi Tub

_____ Glass Shower Enclosure Separate from Tub _____ Other (explain) __________________________

9. HVAC (indicate % unless otherwise noted)

_____Heating System – Average Cost _____ Heating & Central Air Conditioning – Average Cost _____ Heating – Electric

_____ Heating – Gas _____ Heating – Oil _____ Evaporative Coolers _____ Central Air Conditioning – Average Cost _____ Central Air Conditioning – Same Ducts _____ Central Air Conditioning – Separate Ducts

_____ Other (explain) __________________________

10. Miscellaneous Systems

_____ Central Burglar Alarm _____ Central Fire Alarm System _____ Intercom System _____ Central Vacuum System

_____ Interior Sprinkler System _____ Other (explain) __________________________

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