Umbrella Ins. Purl

Umbrella Ins. Purl

This Umbrella 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*
Producer Email*
Assigned PURL*
How did you hear about us? (EN2)*
How did you hear about us? (EN4)*
How did you hear about us? (EN6)*
How did you hear about us? (EN8)*
How did you hear about us? (EN18)*
How did you hear about us? (EN19)*
How did you hear about us? (EN20)*
How did you hear about us? (EN21)*
How did you hear about us? (EN23)*
How did you hear about us? (EN25)*
How did you hear about us? (EN28)*
How did you hear about us? (EN29)*
How did you hear about us? (Charles Phelps)*
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
Applicant Phone Number:*
Gather if not in client file already
Applicant Email Address:
Gather if not in client file already
Marital Status:*
Second Applicant:
First & Last Name *
as listed on driver license
Birthdate*
Date
Gender:*
What is the relationship to the first applicant:*
Applicant's Mailing Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the primary home address the same as mailing address*

YesNo
Primary Home Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Describe your Home*
Personal Property Exposures:
Do you have a Second Vacation/Seasonal Home
*

YesNo
Any Rental Property to be covered by Umbrella
*

YesNo
How many Rental Properties will be added
*
Describe 1st Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 2nd Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 3rd Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 4th Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 5th Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 6th Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 7th Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 8th Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 9th Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Describe 10th Rental Property
*

Single Family (1 unit)Three Family (3 units)Two Family (2 units)Three Family (4 units)
Rental Property Questions:
Are any of the rentals properties public funded (includes Sec 8, HUD, Institutional), or used as student housing
*

YesNo
Please explain*
Does any of the rentals properties provide housing to migrant or temporary workers, or used as adult or child foster care housing or senior assisted living
*

YesNo
Please explain*
Does any of the rental properties have security bars on the windows
*

YesNo
Does the security bars have a built in quick release mechanism
*

YesNo
Does the client own any rural vacant land
*

YesNo
Number of Acres*
Does the client own any urban vacant land
*

YesNo
Number of Acres*
Personal Vehicle Exposures:
Number of Personal Automobiles
What bodily injury limits do you currently have on your personal auto policy*

100,000 per person / 300,000 per accident250,000 per person / 500,000 per accident500,000 per person / 500,000 per accident300,000 combined single limit500,000 combined single limit
Number of Drivers Covered by Umbrella
Driver #1:
First & Last Name*
Relationship
*

SelfOtherChildParentDomestic PartnerRelativeEmployee
Gender
*

MaleFemale
Marital Status
*

SingleWidowedMarriedSeparatedDomestic PartnerDivorced
DOB*
Driver License Number*
DL State*
Driver #2:
First & Last Name*
Relationship
*

SelfOtherChildParentDomestic PartnerRelativeEmployee
Gender
*

MaleFemale
Marital Status
*

SingleWidowedMarriedSeparatedDomestic PartnerDivorced
DOB*
Driver License Number*
DL State*
Driver #3:
First & Last Name*
Relationship
*

SelfOtherChildParentDomestic PartnerRelativeEmployee
Gender
*

MaleFemale
Marital Status
*

SingleWidowedMarriedSeparatedDomestic PartnerDivorced
DOB*
Driver License Number*
DL State*
Driver #4:
First & Last Name*
Relationship
*

SelfOtherChildParentDomestic PartnerRelativeEmployee
Gender
*

MaleFemale
Marital Status
*

SingleWidowedMarriedSeparatedDomestic PartnerDivorced
DOB*
Driver License Number*
DL State*
Driver #5:
First & Last Name*
Relationship
*

SelfOtherChildParentDomestic PartnerRelativeEmployee
Gender
*

MaleFemale
Marital Status
*

SingleWidowedMarriedSeparatedDomestic PartnerDivorced
DOB*
Driver License Number*
DL State*
Number of Personal Motorcycles
*
What bodily injury limits do you currently have on your personal auto policy*

100,000 per person / 300,000 per accident250,000 per person / 500,000 per accident500,000 per person / 500,000 per accident300,000 combined single limit500,000 combined single limit
Number of Personal Motor Homes
*
What bodily injury limits do you currently have on your personal auto policy*

100,000 per person / 300,000 per accident250,000 per person / 500,000 per accident500,000 per person / 500,000 per accident300,000 combined single limit500,000 combined single limit
Watercraft/Boat Exposures:
Number of Boats
*
What bodily injury limits do you currently have on your personal boat policy*

100,000 per person / 300,000 per accident250,000 per person / 500,000 per accident500,000 per person / 500,000 per accident300,000 combined single limit500,000 combined single limit
Number of Class A Utility Boat (under 27 feet and maximum speed of 45 MPH)
*
Number of Class B Standard Boat (under 42 feet and speed in excess of 45 MPH but Max 60 MPH)
*
Number of Class C Yacht/Cruiser, Sailboat, Houseboat (27 feet and over, but under 42 feet, with Max speed 45 MPH)
*
Number of Jetski
*
What bodily injury limits do you currently have on your personal watercraft policy*

100,000 per person / 300,000 per accident250,000 per person / 500,000 per accident500,000 per person / 500,000 per accident300,000 combined single limit500,000 combined single limit
Unlicensed Vehicle Exposures (includes off-road motorcycles, atv, snowmobiles or other unlicensed vehicle)
Number of Unlicensed Vehicle
*
What bodily injury limits do you currently have on your personal unlicensed vehicle policy*

100,000 per person / 300,000 per accident250,000 per person / 500,000 per accident500,000 per person / 500,000 per accident300,000 combined single limit500,000 combined single limit
Describe*
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: