Home Ins. Purl

Completed By:

Agency Name *

enter agency prefix

Producer Names (LSI) *

Producer Names (Rouland) *

Producer Names (HRC) *

Producer Names (JCI) *

Producer Names (Elite One) *

For Edit Submission

Date *

Date

How did you hear about us? *

Referred by: *

If known otherwise type Unknown

Notes:

First Applicant:

First & Last Name *

as listed on driver license

How is the property titled? *

N/A for (Renters Ins - HO4 Policy)

Complete Name of Entity:

Enter complete name of Trust, LLC, Corporation or other

Applicant Home Number:

Gather if not in client file already

Applicant Mobile Number:

Gather if not in client file already

Applicant Email Address:

Gather if not in client file already

Birthdate *

Date

Gender: *

Marital Status: *

Employment Status: *

Emp Status

Occupation / Job Title: *

Example: Science or Engineering Degree

Self-Employed *

Nature of work/business: *

Second Applicant:

First & Last Name *

as listed on driver license

Birthdate *

Date

Gender: *

Applicant Home Number:

Gather if not in client file already

Applicant Mobile Number:

Gather if not in client file already

Applicant Email Address:

Gather if not in client file already

Employment Status: *

Emp Status

Occupation / Job Title: *

Example: Science or Engineering Degree

Self-Employed *

Nature of work/business: *

Applicant Address:

Physical Address (map it) *

	Address
Street
City
State
Zip

(For Email Title)

Address Type *

Street (add 1)

City (add 1)

State (add 1)

Zip (add 1)

Mailing Address (map it) *

	Address
Street
City
State
Zip

Street (add 2)

City (add 2)

State (add 2)

Zip (add 2)

General Policy Information:

HO Form # *

HO3, HO4, HO6, DP3

LOB (for Email Notif)

Describe your Home *

# of families (for mapping FID-293)

How will this home be used? *

X-Primary (for mapping FID-205)

X-Secondary (for mapping FID-207)

X-Owner (for mapping FID-214)

X-Tenant (for mapping FID-215)

X-Vacant (for mapping FID-217)

How will this home be rented? *

How is this Condo/Town Home be used *

X-Primary (for mapping FID-205)

X-Secondary (for mapping FID-207)

X-Owner (for mapping FID-214)

X-Tenant (for mapping FID-215)

X-Vacant (for mapping FID-217)

How is this Condo/Town Home rented *

How is this Manufactured/Mobile Home used *

X-Primary (for mapping FID-205)

X-Secondary (for mapping FID-207)

X-Owner (for mapping FID-214)

X-Tenant (for mapping FID-215)

X-Vacant (for mapping FID-217)

How is this Manufactured/Mobile Home rented *

Will this be a new purchase? *

Is the client buying this home now

Purchase Date (estimate) *

Date

Prior Carrier *

Name of Carrier

Underwriting Questions:

Roof Type Material (Verify on Google Maps , or Instant Street View.com ) *

What is the condition of the Roof *

X-Good (for mapping FID-238)

X-Poor / Below Avg (for mapping FID-240)

What is the Primary Heating System Type *

What Type of Electric Heating do you have? *

What Type of Gas is used? *

Is there a propane storage on premises? *

X-None (for mapping FID-328)

Y/N-Yes or No (for mapping FID-667)

What is location of storage tank? *

X-Indoors Above Ground Masonry Floor (for mapping FID-329)

X-Indoors Above Ground No Masonry Floor (for mapping FID-330)

X-Outdoors Above Ground (for mapping FID-331)

X-Outdoors Below Ground (for mapping FID-332)

Updated within the last 30 years? *

What is the Secondary Heating System Type *

What Type of Electric Heating do you have? *

What is the Electrical System Type *

X-Circuit Breakers (for mapping FID-282)

X-Fuses (for mapping FID-283)

Is the Property currently for sale or planned to be sold in the next 6 months? (By the applicant) *

If the applicant is purchasing the home then put No, only put Yes if the applicant is selling the home.

Y/N - Yes or No (for mapping FID-658)

Is the home under construction? *

Y/N - Yes or No (for mapping FID-673)

FID-673

Will construction be completed before the effective date of the new policy? *

Will Insured have a Licensed General Contractor for the project? *

Type of Project *

What is the Foundation Type *

Finish Type *

Sq Feet of Finished Area *

Do you have a Trampoline on premises? *

Y/N - Yes or No (for mapping FID-661)

FID-661

Anchored to the ground and netted? *

Y/N - Yes or No (for mapping FID-662)

FID-662

Are there dogs on the premises? *

Number of dogs *

What is the breed of dog #1

What is the breed of dog #2

What is the breed of dog #3

What is the breed of dog #4

What is the breed of dog #5

What is the breed of dog #6

What is the breed of dog #1 *

Dog #1

What is the breed of dog #2 *

Dog #2

What is the breed of dog #3 *

Dog #3

What is the breed of dog #4 *

Dog #4

What is the breed of dog #5 *

Dog #5

What is the breed of dog #6 *

Dog #6

Any farm animals? *

e.g. horses, chickens, goats, sheep, cows, etc.

Number of farm animals *

Farm Animal #1 *

Farm Animal #2 *

Farm Animal #3 *

Farm Animal #4 *

Farm Animal #5 *

Farm Animal #6 *

Farm Animal #7 *

Farm Animal #8 *

Farm Animal #9 *

Farm Animal #10 *

Is there a swimming pool on the premises? *

X-None (for mapping FID-310)

FID-310

Is there a diving board? *

X-Diving Board (for mapping FID-314)

FID-314

Is there a water slide? *

X-Slide (for mapping FID-315)

FID-315

Is there a business premises? *

Y/N - Yes or No (for mapping FID-631)

FID-631

Describe (Bus Prem) *

FID-636

Is there a daycare on the premises? *

Number of children *

Do they have a daycare license? *

Do you have General Liability for the Daycare Business? *

Any residence employees? *

Y/N - Yes or No (for mapping FID-639)

FID-639

Describe (Res Emp) *

FID-641

Hours worked per week. *

Does the property have an alarm system? *

What type of Alarm System?

X-Burglar Local (for mapping FID-257)

FID-257

X-Smoke Local (for mapping FID-255)

FID-255

X-Burglar Central (for mapping FID-251)

FID-251

X-Smoke Central (for mapping FID-249a)

FID-249a

Is the property maintained & in good condition *

Is there any unrepaired damage *

Describe any damage *

Is your current/prior policy being canceled for any reason? *

Y/N-Yes or No (for mapping FID-608)

FID-608

Describe/reason: *

Does your home have security bars on the windows *

Do they have a quick release mechanism? *

Is the First / Primary Lender an individual or private person *

Underwriting Questions specific to Manufactured/Mobile Home:

Year Built / Model *

What is the Length *

(In Feet)

What is the Width *

(In Feet)

What is the Type (Wide) *

Located On (Storage) *

Spaces in a Park *

Who owns the Land *

Reconstruction Cost Info:

*

Complete Skip

The following information is not required from the client since all carriers require that we run a cost estimator. However you may want to collect this info for the following reasons.

A. If the client is very detailed and wants to give this information then we can obtain it now.

B. If you are an agent that is very detailed about reconstruction cost and want to come as close as possible to the true replacement cost
of the home.

Year Built *

Square Footage of Living Area *

# of Acreage/Lot size *

Number of Stories *

Number of Fireplaces *

1-# of Chimneys (for mapping FID-300)

1-# of Pre-fab (for mapping FID-302)

# of Exterior Features *

Exterior Features #1 *

Exterior Features #2 *

Exterior Features #3 *

Exterior Features #4 *

What is the Construction Type *

FYI this question/option will import as exterior walls in ezlynx.

X-Masonry Veneer (FID-180)

X-Frame (FID-182)

X-Masonry (FID-184)

Exterior Siding *

X-Aluminum Siding (FID-189)

X-Stucco (FID-191)

X-Vinyl Siding/Plastic (FID-193)

X-Cedar, Wood, Shingle (FID-195)

X-EIFSCB (on cinder block) -(FID-197)

X-EIFSS (on studs) -(FID-199)

X-Other (FID-201)

Other (Ext Walls) *

Garage & Carports *

# of Additional Attached Structures *

Attached Structures #1 *

Size in sq ft *

Attached Structures #2 *

Size in sq ft *

Attached Structures #3 *

Size in sq ft *

Attached Structures #4 *

Size in sq ft *

Total # of Kitchens *

Grade of Kitchen #1 *

Grade of Kitchen #2 *

Grade of Kitchen #3 *

Grade of Kitchen #4 *

Total # of Full Bathrooms *

Grade of Full Bathroom #1 *

Grade of Full Bathroom #2 *

Grade of Full Bathroom #3 *

Grade of Full Bathroom #4 *

Grade of Full Bathroom #5 *

Grade of Full Bathroom #6 *

Grade of Full Bathroom #7 *

Grade of Full Bathroom #8 *

Total # of 1/2 Bathrooms *

Grade of 1/2 Bathroom #1 *

Grade of 1/2 Bathroom #2 *

Grade of 1/2 Bathroom #3 *

Grade of 1/2 Bathroom #4 *

Grade of 1/2 Bathroom #5 *

Grade of 1/2 Bathroom #6 *

Grade of 1/2 Bathroom #7 *

Grade of 1/2 Bathroom #8 *

Air Conditioning *

Floor Finishes *

# of Split/Multiple Types *

Floor Finishes #1 *

Floor Finishes #2 *

Floor Finishes #3 *

Wall Finishes *

# of Split/Multiple Types *

Wall Finishes #1 *

Wall Finishes #2 *

Wall Finishes #3 *

# of Indoor Features *

Indoor Features #1 *

Size in sq ft *

Indoor Features #2 *

Size in sq ft *

Indoor Features #3 *

Size in sq ft *

Indoor Features #4 *

Size in sq ft *

Policy Coverage:

*

Complete Skip

The following information is not required from the client since we automatically include all the standard coverages available on the policies and we will provide a proposal that explains all the coverage options and limits in detail. However you may want to go over the specifics for following reasons.

A. If the client is very detailed and wants to match coverage from a prior policy or wants specific limits on certain line of coverage.

B. If you are an agent that prefer to review/explain the coverage prior to the release of an actual proposal to determine what the client is looking for.

Dwelling Coverage Amount *

Cost per Square Foot *

txt

Cov. A with Extended Replacement *

Extended Replacement Cost *

Choose None if condo/townhome

txt

Detached Structure *

txt

Personal Property

Note: If you are completing the acord application specifically to submit to wholesalers (non-admitted) then you must enter the desire amount so it can appear on the acord 80.

Loss of Use

Note: If you are completing the acord application specifically to submit to wholesalers (non-admitted) then you must enter the desire amount so it can appear on the acord 80.

Loss of Rents *

txt

Comprehensive Personal Liability *

Owners, Landlord & Tenant Liability (OL&T) *

Medical Payments (for mapping FID-102) *

Water/Sewer Backup *

Other Specific Limit *

Enter the specific limit

Ordinance of Law Coverage *

X-Ord or Law (for mapping FID-441)

Other Specific Limit (Ord of Law) *

Enter the specific limit

Identity Theft Coverage *

Scheduled Personal Property *

Put "0" (zero) for items not required *

Notes:

Condo Coverage

Dwelling Coverage Amount (Condo) *

will be calculated by carrier system

Dwelling Coverage Specific Limit (Condo) *

Notes:

Personal Property (Condo) *

will be calculated by carrier system

Personal Property Specific Limit (Condo) *

Notes:

Condo-Loss of Use *

will be calculated by carrier system

Loss of Use Specific Limit (Condo) *

Notes:

Personal Liability (Condo) *

Loss of Rents/Fair Rental Value *

will be calculated by carrier system

Loss of Rents Specific Limit *

Notes:

Loss Assessment *

will be calculated by carrier system

Loss Assessment Specific Limit *

Notes:

Additional Underwriting:

*

Complete Skip

Note: This section/questions is not required for any specific underwriting purpose. However it should be completed to save time avoid duplicate entry. By completing this section then it will bridge all the information into an accord application which is then used to create the client entry and risk entry in ezlynx.

Agency *

Agency Address

	Address
Street
City
State
Zip

Street (Agency)

City (Agency)

State (Agency)

Zip (Agency)

Agency Contact Name *

Agency Phone # *

Agency Fax # *

Agency Email Address *

Enter the email of the Account Manager

This section of Additional Underwriting questions is specific to HO3, HO6 and DP3 to complete the acord application and to bridge to all fields into EZLynx:

Location # *

Construction Style *

X-Apartment (for mapping FID-221)

X-Condominium (for mapping FID-222)

X-Dwelling (for mapping FID-220)

X-Rowhouse (for mapping FID-224)

X-Townhouse (for mapping FID-223)

X-Rambler/Ranch/Victorian (for mapping FID-226)

FID-226

Other Const. Style (for mapping FID-227)

FID-227

Purchase Price *

Housekeeping Condition *

X-Good (for mapping FID-229)

Plumbing Condition *

X-Good (for mapping FID-234)

Visible from Road *

X-Visible from Road (for mapping FID-247)

Occupied Daily *

X-Occupied Daily (for mapping FID-249)

Visible to Neighbors *

X-Visible to Neighbors (for mapping FID-248)

Fire Extinguisher *

Y/N-Fire Extinguisher (for mapping FID-269)

Distance to Fire Hydrant *

In Feet

Distance to Fire Station *

In Miles

Type of Wiring *

X-Copper (for mapping FID-278)

X-Aluminum (for mapping FID-279)

X-Knob & Tube (for mapping FID-280)

In City Limits *

If unknown enter YES

X-In City Limits (for mapping FID-318)

In Fire District *

If unknown enter YES

X-In Fire District (for mapping FID-319)

Foundation *

X-Open (for mapping FID-326)

X-Closed (for mapping FID-327)

Year of Wiring Renovation *

estimated year of update

Year of Plumbing Renovation *

estimated year of update

Year of Heating Renovation *

estimated year of update

Year of Roof Renovation *

estimated year of update

This section of Additional Underwriting questions is specific for an HO6 to complete the acord application and to bridge to all fields into EZLynx:

Year Built (HO6) *

Square Footage of Living Area (HO6) *

Roof Type Material (Verify on Google Maps , or Instant Street View.com ) (HO6) *

Exterior Siding (HO6) *

X-Aluminum Siding (HO6 FID-189)

X-Stucco (HO6 FID-191)

X-Vinyl Siding/Plastic (HO6 FID-193)

X-Cedar, Wood, Shingle (HO6 FID-195)

X-EIFSCB (on cinder block) -(HO6 FID-197)

X-EIFSS (on studs) -(HO6 FID-199)

X-Other (HO6 FID-201)

Other (HO6 Ext Walls) *

Dwelling Type (HO6) *

What is the Primary Heating System Type (HO6) *

Smoke Detector (HO6) *

X-Smoke Detector (HO6)

Is there a swimming pool on the premises? (HO6) *

X-None (HO6 FID-310)

FID-310

Is there a diving board? *

X-Diving Board (HO6 FID-314)

FID-314

Is there a water slide? *

X-Slide (HO6 FID-315)

FID-315

This section of Additional Underwriting is specific for an HO4 to complete the acord application:

Year Built (HO4) *

Square Footage of Living Area (HO4) *

Roof Type Material (Verify on Google Maps , or Instant Street View.com ) (HO4) *

Exterior Siding (HO4) *

X-Aluminum Siding (HO4 FID-189)

X-Stucco (HO4 FID-191)

X-Vinyl Siding/Plastic (HO4 FID-193)

X-Cedar, Wood, Shingle (HO4 FID-195)

X-EIFSCB (on cinder block) -(HO4 FID-197)

X-EIFSS (on studs) -(HO4 FID-199)

X-Other (HO4 FID-201)

Other (HO4 Ext Walls) *

Dwelling Type (HO4) *

Occupied Daily (HO4) *

X-Occupied Daily (HO4 FID-249)

What is the Primary Heating System Type (HO4) *

Smoke Detector (HO4) *

X-Smoke Detector (HO4)

Fire Extinguisher (HO4) *

Y/N-Fire Extinguisher (HO4)

Is there a swimming pool on the premises? (HO4) *

X-None (HO4 FID-310)

FID-310

Is there a diving board? *

X-Diving Board (HO4 FID-314)

FID-314

Is there a water slide? *

X-Slide (HO4 FID-315)

FID-315

Prior Coverage:

Prior Policy Number *

Prior Policy Expiration Date *

Loss History:

Any losses, whether or not paid by insurance, during the last 5 years at this or any location? *

Y/N-Yes or No (for mapping FID-382)

How many losses? *

How many losses? (DP3) *

Loss Date (1st Loss) *

Loss Type (1st Loss) *

Description of Loss (1st Loss) *

Amount Paid (1st Loss) *

Loss Date (2nd Loss) *

Loss Type (2nd Loss) *

Description of Loss (2nd Loss) *

Amount Paid (2nd Loss) *

Loss Date (3rd Loss) *

Loss Type (3rd Loss) *

Description of Loss (3rd Loss) *

Amount Paid (3rd Loss) *

Loss Date (4th Loss) *

Loss Type (4th Loss) *

Description of Loss (4th Loss) *

Amount Paid (4th Loss) *

General Information:

1. Any other insurance with this company? *

Y/N-Yes or No (for mapping FID-603A)

2. Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past five (5) years? *

Y/N-Yes or No (for mapping FID-610)

3. Has the applicant had a judgement or lien during the past five (5) years? *

Y/N-Yes or No (for mapping FID-612)

4. Any other residence, not listed on any application, owned, occupied or rented? *

Y/N-Yes or No (for mapping FID-614)

5. Has insurance been transferred with agency? *

Y/N-Yes or No (for mapping FID-617)

6. Does applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes, ATVs, etc), not scheduled on this policy? *

Y/N-Yes or No (for mapping FID-619)

7. During the last five (5) years, has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson-related crime in connection with this or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.) *

Y/N-Yes or No (for mapping FID-628)

General Information - Residential:

1. Any flooding, brush, forest fire or landslide hazard? *

Y/N-Yes or No (for mapping FID-644)

2. Are there any animals or exotic pets kept on premises? *

Y/N-Yes or No (for mapping FID-646)

3. Is property situated on more that one acre? *

Y/N-Yes or No (for mapping FID-653)

If "YES", what is the land used for: *

4. Any uncorrected fire or building code violations? *

Y/N-Yes or No (for mapping FID-656)

5. Is property within 300 feet of a commercial or non-residential property? *

Y/N-Yes or No (for mapping FID-659)

If "YES", describe in detail

6. Was the structure originally built for other than a private residence and then converted? *

Y/N-Yes or No (for mapping FID-663)

If "Yes", what is the original occupancy: *

7. Any lead paint? *

Y/N-Yes or No (for mapping FID-665)

8. Is the residence on a gated community? *

Y/N-Yes or No (for mapping FID-671)

If "Yes", what is the Name of Community: *

9. Is there an approved carbon monoxide alarm in operating condition within the mandated number of feet of every room used for sleeping purposes? (IL - 15 FT) (no explanation needed) *

Y/N-Yes or No (for mapping FID-685)

10. Is the named insured the owner of the property? (If "NO", provide the name of the owner) *

Y/N-Yes or No (for mapping FID-686)

OWNER'S NAME: *

Additional Interest:

# of Additional Interest *

# of Additional Interest (DP3) *

Additional Interest #1 *

Other Additional Interest (1st Add Int) *

Specify other additional interest

X-Additional Insured (for mapping FID-697)

X-Lienholder (for mapping FID-698)

X-Loss Payee (for mapping FID-699)

X-Mortgagee (for mapping FID-700)

X-Trustee (for mapping FID-701)

X-Other (for mapping FID-702)

Name of Additional Interest (1st Add Int) *

Mailing / Street Address (1st Add Int) *

City (1st Add Int) *

State (1st Add Int) *

Postal / Zip Code (1st Add Int) *

Additional Interest #2 *

Other Additional Interest (2nd Add Int) *

Specify other additional interest

X-Additional Insured (for mapping FID-722)

X-Lienholder (for mapping FID-723)

X-Loss Payee (for mapping FID-724)

X-Mortgagee (for mapping FID-725)

X-Trustee (for mapping FID-726)

X-Other (for mapping FID-727)

Name of Additional Interest (2nd Add Int) *

Mailing / Street Address (2nd Add Int) *

City (2nd Add Int) *

State (2nd Add Int) *

Postal / Zip Code (2nd Add Int) *

Deductible on ACORD:

Policy Deductible *

To be shown on the ACORD

Attachments: (Optional)

Upload a File

Copy of prior policy or prior declarations, etc

Notes:

Collect Quote info another LOB *

Are you ready to send to CPA and validate *

Yes No

Now choose the CPA to help you find a market *

* If you want to send to LSI Quoting Team to do the CPA do not answer the 2nd question or select "None (do not proceed to CPA)" then select "No Other LOB (send to LSI Quoting Team)" on the first question.

* This will transfer the client info to another quote form to save time. Example - if a client calls for a home quote but also wants an auto quote. The you can transfer the data to the auto quote form and eliminate typing the same information multiple times.