Comprehensive Personal Liability (CPL) Purl

Comprehensive Personal Liability (CPL) Purl

This CPL 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*

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:*

CPL Exposures:

How many Properties are you wishing to cover on this CPL Policy*

1324

Note: Do not confuse with the number of buildings per location. If there are 2 buildings on the same lot then its still 1 location.

Location 1 Info:

How many buildings are at this location*

132

What is the address of the 1st building for location 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 2nd building for location 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 3rd building for location 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

Location 2 Info:

How many buildings are at this location*

132

What is the address of the 1st building for location 2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 2nd building for location 2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 3rd building for location 2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

Location 3 Info:

How many buildings are at this location*

132

What is the address of the 1st building for location 3*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 2nd building for location 3*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 3rd building for location 3*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

Location 4 Info:

How many buildings are at this location*

132

What is the address of the 1st building for location 4*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 2nd building for location 4*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

What is the address of the 3rd building for location 4*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of this building *

How will this Home be used*

How will this Home be rented*

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

Physical Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Describe your Home*

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.