Home Ins. Purl

Home Ins. Purl

This Homeowners PURL is used ot collect risk information for the purpose of quoting. Do not give or share with clients, in house use ONLY.
Agency Name*
enter agency prefix
Producer Names*
Assigned PURL*
How did you hear about us?*
Referred by:*
If known otherwise type Unknown
Notes:
Page URL
For Edit Submission
Date*

MonthDayYear
Date
LOB*
Ezlynx Client:
Does the client already exist in ezlynx
What is the Ezlynx Client ID*
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 Phone Number:*
Gather if not in client file already
Applicant Email Address:
Gather if not in client file already
Birthdate*
Date
Gender:*
Marital Status:*
Second Applicant:
First & Last Name *
as listed on driver license
Birthdate*
Date
Marital Status:*
Applicant Address:
Physical Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address Type*
Line of Business to Quote*

Standard Fire (Full Policy)DIC Only (Difference in Conditions)Flood InsEarthquake Ins
Mailing Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Policy Information:
Describe your Home*
Does each unit have its own address number since this is a Multi Unit Building. *
Example: If its a triplex and has Unit 222, 224, & 226
How will this home be used?*
How will this home be rented?*
How is this Condo/Town Home be used*
How is this Condo/Town Home rented*
How is this Manufactured/Mobile Home used*
How is this Manufactured/Mobile Home rented*
What is the Address for the 1st Unit*
What is the Address for the 2nd Unit*
What is the Address for the 3rd Unit*
What is the Address for the 4th Unit*
Will this be a new purchase?*
Is the client buying this home now
Estimated Closing Date*
When will the applicant become the new owner
Will the property be fully occupied within 30 days after the close f escrow.*
Is the client buying this home now
How long will the work take to complete *
Is the client buying this home now
Is this home currently Insured*
Prior Carrier*
Name of Carrier*
Expiration Date*
What is the Term of the Policy*
Please indicate all the reasons why the policy will not be renewed*

History of ClaimsExposure to Wildfire / Located in Brush AreaCarrier no longer doing business in CaliforniaCondition of Main HomeCondition or Type of Detached StructureCondition of the RoofUnacceptable Dog Breed or Animal (s)Age of BuildingType of Electrical SystemType of of PlumbingType of HeatingOther
Detached Strucures Information:
Are there any detached structures of any kind on this lot
YesNo
How many detached structures are there
1324
Describe the 1st detached structure*
Describe the Garage Type*
Describe the Barn Type*
Describe the Additional House*
Describe the Workshop*
Describe this Other Structure*
What is the Total Square Footage*
Describe the 2nd detached structure*
Describe the Garage Type*
Describe the Barn Type*
Describe the Additional House*
Describe the Workshop*
Describe this Other Structure*
What is the Total Square Footage*
Describe the 3rd detached structure*
Describe the Garage Type*
Describe the Barn Type*
Describe the Additional House*
Describe the Workshop*
Describe this Other Structure*
What is the Total Square Footage*
Describe the 4th detached structure*
Describe the Garage Type*
Describe the Barn Type*
Describe the Additional House*
Describe the Workshop*
Describe this Other Structure*
What is the Total Square Footage*
Underwriting Questions:
Section - Underwriting Questions for 1-4 Units
Is the Roof in poor condition or near end of life
YesNo
Is it a Woodshake Roof
YesNo
Is the primary heating system powered by other than natural gas and/or electric
YesNo
How is it powered
Fireplace (Wood)Geo Thermal (Open Loop)Geo Thermal (Closed Loop)PropaneKeroseneOther
What type of electrical panel does the home have.
Circuit BreakersFuses
Is the panel made by Federal Pacific, Zinsco, GTE Sylvania *

Federal PacificZinscoGTE SylvaniaFPE Stab-LokNone of thisI do not know
Is the home undergoing any remodling or renovation
YesNo
Will construction work be completed before the effective date of the new policy
YesNo
Does the home have a Post and Pier Foundation
YesNo
Is there a Trampoline on premises?
YesNo
Anchored to the ground and netted
YesNo
Are there any farm animals
YesNo
How many types of farm animals
1324
1st Farm Animal type*
How Many*
2nd Farm Animal type*
How Many*
3rd Farm Animal type*
How Many*
4th Farm Animal type*
How Many*
Is there a swimming pool on the premises
YesNo
Does it have any of the following
Diving BoardWaterslideNone
Is the Property currently for sale or planned to be sold in the next 6 months? (By the applicant)*
YesNo
Is your current/prior policy being canceled for any reason
YesNo
Explain Why*
Are there Dogs on the premises
YesNo
Number of dogs
1324
1 - What is the Specific Dog Breed
2 - What is the Specific Dog Breed
3 - What is the Specific Dog Breed
4 - What is the Specific Dog Breed
Have you had any homeowner insurance claims in the last 5 years
YesNo
Number of claims
1324
1 - Approximately when did this claim occur and a brief description
2 - Approximately when did this claim occur and a brief description
3 - Approximately when did this claim occur and a brief description
4 - Approximately when did this claim occur and a brief description
Is your home protected by an alarm system
YesNo
What type of alarm does the home have
Local Alarm (loud sound only)Monitored burglar alarm (central reporting)Monitored fire alarm (central reporting)Monitored burglar & fire alarm (central reporting)
Note: Having an alarm system will give a discount on the policy. The client will have to call the alarm company and request alarm certificate if its a monitored alarm system. We cannot accept a copy of any application, or screenshot, or copy of the bill. Only the alarm certificate is acceptable and nothing else.
We must have the certificate before binding the policy with the discount. Do not bind the policy with the discount and try to get the proof after. Just remove the discount and it can be added at anytime later when the client gives the proof aka certificate.
Section - Underwriting Questions for Condo / Townhome requiring HO6 Policy
Is your current/prior policy being canceled for any reason
YesNo
Explain Why*
Are there Dogs on the premises
YesNo
Number of dogs
1324
1 - What is the Specific Dog Breed
2 - What is the Specific Dog Breed
3 - What is the Specific Dog Breed
4 - What is the Specific Dog Breed
Section - Underwriting Questions for Mobile / Manufactured Homes
Is the Roof in poor condition or near end of life
YesNo
Is the primary heating system powered by other than natural gas and/or electric
YesNo
How is it powered
Fireplace (Wood)Geo Thermal (Open Loop)Geo Thermal (Closed Loop)PropaneKeroseneOther
Are there any farm animals
YesNo
How many types of farm animals
1324
1st Farm Animal type*
How Many*
2nd Farm Animal type*
How Many*
3rd Farm Animal type*
How Many*
4th Farm Animal type*
How Many*
Is your current/prior policy being canceled for any reason
YesNo
Explain Why*
Are there Dogs on the premises
YesNo
Number of dogs
1324
1 - What is the Specific Dog Breed
2 - What is the Specific Dog Breed
3 - What is the Specific Dog Breed
4 - What is the Specific Dog Breed
Community type location
Located in a parkLocated in a subdivisionLocated in private property
What is the name of the park
Is there a full time resident manager
YesNo
Total number of spaces in park
What is the year built
What is the structure type
Single WideDouble Wide
What is the length
What is the width
Section - Underwriting Questions for Renters requiring an HO4 Policy
Is your current/prior policy being canceled for any reason
YesNo
Explain Why*
Are there Dogs on the premises
YesNo
Number of dogs
1324
1 - What is the Specific Dog Breed
2 - What is the Specific Dog Breed
3 - What is the Specific Dog Breed
4 - What is the Specific Dog Breed
Policy Coverage:
CompleteSkip
Section: (For buildings 1-4 Units)
Dwelling Coverage*
Coverage A Limit
Detached Structure*
Coverage B Limit
Personal Property*
Coverage C Limit
Loss of Use / Loss of Rents*
Coverage D Limit
Personal Liability*
Coverage E Limit
Medical Payments*
Coverage F Limit
Water Backup / Sewer Backup*
Ordinance of Law Coverage*
Identity Theft Coverage*
Personal Injury*
Scheduled Personal Property*
Put "0" (zero) for items not required*
Notes:
Section: (For Condo or Townhome Requiring an HO6 Policy)
Dwelling Coverage*
Coverage A Limit
Personal Property*
Coverage C Limit
Loss of Use / Loss of Rents*
Coverage D Limit
Personal Liability*
Coverage E Limit
Medical Payments*
Coverage F Limit
Water Backup / Sewer Backup*
Ordinance of Law Coverage*
Identity Theft Coverage*
Personal Injury*
Scheduled Personal Property*
Put "0" (zero) for items not required*
Section: (For Mobile / Manufactured Homes)
Dwelling Coverage*
Coverage A Limit
Detached Structure*
Coverage B Limit
Personal Property*
Coverage C Limit
Loss of Use / Loss of Rents*
Coverage D Limit
Personal Liability*
Coverage E Limit
Medical Payments*
Coverage F Limit
Water Backup / Sewer Backup*
Ordinance of Law Coverage*
Identity Theft Coverage*
Personal Injury*
Scheduled Personal Property*
Put "0" (zero) for items not required*
Section: (For Renters requiring an HO4 Policy)
Personal Property*
Coverage C Limit
Loss of Use / Loss of Rents*
Coverage D Limit
Personal Liability*
Coverage E Limit
Medical Payments*
Coverage F Limit
Water Backup / Sewer Backup*
Identity Theft Coverage*
Personal Injury*
Scheduled Personal Property*
Put "0" (zero) for items not required*
Attachments: (Optional)

Upload a File
Copy of prior policy or prior declarations, etc Cancelof
Notes:
Help me find a Market nowNo - Not right now
Note: This will transfer the information from this form (Purl) to the matching CPA to help you shop all the carriers and determine the best options.
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