Earthquake Ins. Purl

Earthquake Ins. Purl

This Earthquake 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:
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
Gender:*
Applicant Address:
Physical Address (map it) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address Type*
Mailing Address (map it) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Policy Information:
Describe your Home*
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*
Will this be a new purchase?*
Is the client buying this home now
Prior Carrier
Expiration Date
Name of Carrier
Underwriting Questions:
Is there a Basement
YesNo
Total # of Floors (including Basement)
132more than 3
What is the construction type
Wood FrameReinforced MasonryUnreinforced MasonryReinforced ConcreteSteel FrameModular / Mobile Home
What is the dwelling Foundation Type
Crawl SpaceConcrete SlabBasementPost & Pier Foundation
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
Ordinance of Law Coverage*
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
Ordinance of Law Coverage*
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
Ordinance of Law Coverage*
Section: (For Renters requiring an HO4 Policy)
Personal Property*
Coverage C Limit
Loss of Use / Loss of Rents*
Coverage D Limit
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.
Should be Empty: