Boat Ins. Purl

Boat Ins. Purl

This Boat PURL is used to collect risk information for the purpose of quoting. Do not give or share with clients, in house use ONLY.

Completed By:

Agency Name*

enter agency prefix

Producer Names*

Assigned PURL*

Page URL

For Edit Submission

Date*

Date

LOB*

Time*

:HourMinutesAM/PM Option

How did you hear about us?*

Referred by:*

If known otherwise type Unknown

Notes:

Prior Ins. Policy Info:

Prior Carrier*

Name of Carrier

When does the policy expire

enter the exp/renewal date

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

Will be listed as Driver? (1st applicant)*

Reason for Exclusion*

Explain why Excluded:*

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:*

Driver License Number*

License State*

Employment Status*

Occupation / Job Title*

Example: Science or Engineering Degree

Self-Employed?*

Nature of work/business (applicant 1)*

Address of Business/Employer (applicant 1)*

Address of School/College*

Street Address Line 2

Good Student (Discount)*

Must have 3.0 or better GPA with 12 Units or More

Second Applicant:

First & Last Name (2nd applicant)*

as listed on driver license

Will be listed as Driver? (2nd applicant)*

Relationship to First Named Insured:*

Relationship (2nd app)

Reason for Exclusion*

Explain why Excluded:*

Birthdate*

Date

Gender:*

Gender (2nd app)

Marital Status:*

Marital (2nd app)

Driver License Number*

License State*

Employment Status*

Occupation / Job Title*

Example: Science or Engineering Degree

Self-Employed?*

Nature of work/business (applicant 2)*

Address of Business/Employer (applicant 2)*

Street Address Line 2

Address of School/College*

Street Address Line 2

Good Student (Discount)*

Must have 3.0 or better GPA with 12 Units or More

Applicant Address:

Garaging Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address Type*

Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Add Driver? (1st driver)*

First & Last Name (1st driver)*

as listed on driver license

Relationship to First Named Insured (1st driver)*

Birthdate (1st driver)*

Date

Gender (1st driver)*

gender 1st driver (map to pdf)

Marital Status (1st driver)*

Driver License Number (1st driver)*

License State (1st driver)*

Type of Driver License (1st driver)

Class M Endorsed on License

Years Operating Experience (1st driver)

Experience of Motorcycle / ATV Riding

Employment Status (1st driver)*

Occupation / Job Title (1st driver)*

Example: Science or Engineering Degree

Self-Employed? (1st driver)*

Nature of work/business (1st driver)*

Address of Business/Employer (1st driver)*

Street Address Line 2

Address of School/College (1st driver)*

Street Address Line 2

Good Student (Discount) (1st driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (2nd driver)*

First & Last Name (2nd driver)*

as listed on driver license

Relationship to First Named Insured (2nd driver)*

Birthdate (2nd driver)*

Date

Gender (2nd driver)*

gender 2nd driver (map to pdf)

Marital Status (2nd driver)*

Driver License Number (2nd driver)*

License State (2nd driver)*

Type of Driver License (2nd driver)

Class M Endorsed on License

Years Operating Experience (2nd driver)

Experience of Motorcycle / ATV Riding

Employment Status (2nd driver)*

Occupation / Job Title (2nd driver)*

Example: Science or Engineering Degree

Self-Employed? (2nd driver)*

Nature of work/business (2nd driver)*

Address of Business/Employer (2nd driver)*

Street Address Line 2

Address of School/College (2nd driver)*

Street Address Line 2

Good Student (Discount) (2nd driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (3rd driver)*

First & Last Name (3rd driver)*

as listed on driver license

Relationship to First Named Insured (3rd driver)*

Birthdate (3rd driver)*

Date

Gender (3rd driver)*

gender 3rd driver (map to pdf)

Marital Status:*

Driver License Number (3rd driver)*

License State (3rd driver)*

Type of License (3rd driver)

Class M Endorsed on License

Years Operating Experience (3rd driver)

Experience of Motorcycle / ATV Riding

Employment Status (3rd driver)*

Occupation / Job Title (3rd driver)*

Example: Science or Engineering Degree

Self-Employed? (3rd driver)*

Nature of work/business (3rd driver)*

Address of Business/Employer (3rd driver)*

Street Address Line 2

Address of School/College (3rd driver)*

Street Address Line 2

Good Student (Discount) (3rd driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (4th driver)*

First & Last Name (4th driver)*

as listed on driver license

Relationship to First Named Insured (4th driver)*

Birthdate (4th driver)*

Date

Gender (4th driver)*

gender 4th driver (map to pdf)

Marital Status:*

Driver License Number (4th driver)*

License State (4th driver)*

Type of Driver License (4th driver)

Class M Endorsed on License

Years Operating Experience (4th driver)

Experience of Motorcycle / ATV Riding

Employment Status (4th driver)*

Occupation / Job Title (4th driver)*

Example: Science or Engineering Degree

Self-Employed? (4th driver)*

Nature of work/business (4th driver)*

Address of Business/Employer (4th driver)*

Street Address Line 2

Address of School/College (4th driver)*

Street Address Line 2

Good Student (Discount) (4th driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (5th driver)*

First & Last Name (5th driver)*

as listed on driver license

Relationship to First Named Insured (5th driver)*

Birthdate (5th driver)*

Date

Gender (5th driver)*

gender 5th driver (map to pdf)

Marital Status:*

Driver License Number (5th driver)*

License State (5th driver)*

Type of Driver License (5th driver)

Class M Endorsed on License

Years Operating Experience (5th driver)

Experience of Motorcycle / ATV Riding

Employment Status (5th driver)*

Occupation / Job Title (5th driver)*

Example: Science or Engineering Degree

Self-Employed? (5th driver)*

Nature of work/business (5th driver)*

Address of Business/Employer (5th driver)*

Street Address Line 2

Address of School/College (5th driver)*

Street Address Line 2

Good Student (Discount) (5th driver)*

Must have 3.0 or better GPA with 12 Units or More

Policy Coverage:

Collect Policy Coverage Info now*

YesNo (client will email/text us the info)

Liability (Bodily Injury)

Limit per person

Liability (Bodily Injury)

Limit per accident

Liability (Property Damage)

Limit per accident

Uninsured Boaters (Bodily Injury)

Limit per person

Uninsured Boaters (Bodily Injury)

Limit per accident

Medical Payments

Limit per accident

Boats on the Policy:

1-Type of Boat/Yacht*

Usage*

Hull ID Number*

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Sub Model*

Actual Cash Value*

Propulsion Type*

Number of Motors*

Horsepower per Motor*

Fuel Type*

Maximum Boat Speed*

Length (feet)*

Ownership Type*

Purchased Date*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance (vehicle 1)

Towing and labor

Do you want to add a 2nd vehicle?

2-Type of Boat/Yacht

Usage*

Hull ID Number*

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Sub Model*

Actual Cash Value*

Propulsion Type*

Number of Motors*

Horsepower per Motor*

Fuel Type*

Maximum Boat Speed*

Length (feet)*

Ownership Type*

Purchased Date*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance (vehicle 2)

Towing and labor

Do you want to add a 3rd vehicle?

3-Type of Boat/Yacht

Usage*

Hull ID Number*

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Sub Model*

Actual Cash Value*

Propulsion Type*

Number of Motors*

Horsepower per Motor*

Fuel Type*

Maximum Boat Speed*

Length (feet)*

Ownership Type*

Purchased Date*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance (vehicle 3)

Towing and labor

Attachments: (Optional)

Upload a File

Copy of Policy, Drivers License, ETC

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.