Vacant Land Ins. Purl

Vacant Land Ins. Purl

This Flood 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*

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?*

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:*

What is the relationship to the first applicant:*

Applicant Address:

Does the property have an actual address or just a parcel number (APN)*

Physical Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is the Parcel Number (APN)*

Mailing Address (map it) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Underwriting Questions:

How many different Vacant Land are to be covered by this Policy

12

1st Property:

What is the Vacant land type

Rural / RemoteUrban / Populated Area

Are there any structures of any kind at this location.

YesNo

Describe the Structure (s)

Please explain*

Is this vacant land ever rented out for any reason.

YesNo

Describe the reason (s)

Animal GrazingCampingHunting / FishingOther Activities

Please explain*

is there any fencing around the property.

YesNo

2nd Property:

What is the Vacant land type

Rural / RemoteUrban / Populated Area

Are there any structures of any kind at this location.

YesNo

Describe the Structure (s)

Please explain*

Is this vacant land ever rented out for any reason.

YesNo

Describe the reason (s)

Animal GrazingCampingHunting / FishingOther Activities

Please explain*

is there any fencing around the property.

YesNo

Attachments: (Optional)

Upload a File

Copy of prior policy or prior declarations, 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.