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Home Replacement Cost Appraisal Analysis Form
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First Name - Insured 1
What is the insured's first name?
Last Name - Insured 1
What is the insured's last name?
Email address
What is the insured's email address?
Appraisal Address
What is the address of the home that was appraised?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Year Built
What year was this house built?
Appraising Insurance Company Name
What is the name of the insurance company that appraised the home?
AIG Private Client Group
Berkley One
Central Insurance
Cincinnati Insurance
Chubb Personal Risk Services
Hanover Insurance
National General
PURE Insurance
Other
Other Insurance Company Name
Please enter the name of the insurance company that appraised this home.
Replacement Cost Factors - Pre-Appraisal
Original Replacement Cost Estimate
Please enter the original replacement cost estimate.
Original Square Footage
Please enter the original square footage used to estimate the replacement cost of this home.
Original Cost per Square Foot
Original Cost per Square Foot
Homeowners Premium Proposed
Enter the proposed annual premium.
Replacement Cost Factors - Post-Appraisal
Replacement Cost Appraisal
What is the appraised replacement cost?
Appraised Square Footage
Please enter the total square footage of the living space listed on the appraisal.
Appraised Cost per Square Foot
Appraised Cost per Square Foot
Homeowners Premium Final
Enter the annual homeowners premium with the appraisal impact.
Replacement Cost Analysis
Appraisal Impact?
What impact did the appraisal have on the policy premium?
Increased the Premium
Decreased the Premium
No Impact on Premium
Premium Increase Due to Appraisal
Premium Increase Due to Appraisal
Premium Decrease Due to Appraisal
Premium Descrease Due to Appraisal
Appraisal Change Processing Date
What date will the changes mentioned in the appraisal be processed?
MM slash DD slash YYYY
Any Critical Requirements?
Are there any critical requirements from the appraisal that must be complied with?
Yes
No
Appraisal Requirements
Critical Requirements
Please select the critical requirements requested by the insurance company. (Select all that apply)
Install a central station fire alarm
Install a central station burglar alarm
Install an automatic water shutoff valve
Other
Other Critical Requirement
Please enter any other critical requirements from the appraisal below.
Critical Requirements Due Date
What date is evidence of the critical requirements needed.
MM slash DD slash YYYY
Appraisal Automation Options
Appraisal Automation Check boxes
Please select the notifications you would like to trigger. (Note: A Zapier integration must be set up for these options to work.)
Email to client
Email to producer
Email to account manager
Email to carrier
Critical Requirement(s) reminder
Add data to spreadsheet
Client name
What is the client's name? (As you would like it to appear in the email.)
Client email
What is the client's email address?
Producer name
What is the producer's name? (As you would like it to appear in the email.)
Producer email
What is the producer's email address?
Account manager name
What is the account manager's name? (As you would like it to appear in the email.)
Account manager email
What is the Account manager's email address?
Carrier rep name
What is the carrier representative's name? (As you would like it to appear in the email.)
Carrier rep email
What is the carrier representative's email address?
Consent
*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree
Kurt Thoennessen, CAPI
(203) 405-2645
http://ajg.com/
kurt_thoennessen@ajg.com
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