Earthquake Ins. Purl

Earthquake Ins. Purl

This Earthquake 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 *
Producer Name (LSI) *
Producer Name (Rouland) *
Producer Name (HRC) *
Producer Name (JCI) *
Producer Name (Elite One) *
For Edit Submission
Date *

Month Day Year
Date
How did you hear about us? *
Referred by: *
If known otherwise type Unknown
Notes:
First Applicant:
First & Last Name (1st App) *
as listed on driver license
How is the property titled? *
Complete Name of Entity:
Enter complete name of Trust, LLC, Corporation or other
Applicant Home Number (1st App)
Gather if not in client file already
Applicant Mobile Number (1st App)
Gather if not in client file already
Applicant Email Address (1st App)
Gather if not in client file already
Birthdate (1st App) *
Date
Gender (1st App) *
Marital Status (1st App) *
Employment Status (1st App)
Occupation / Job Title (1st App) *
Example: Science or Engineering Degree
Self-Employed? (1st App) *
Nature of work/business (1st App) *
Second Applicant:
First & Last Name (2nd App) *
as listed on driver license
Birthdate (2nd App) *
Date
Gender (2nd App) *
Applicant Home Number (2nd App):
Gather if not in client file already
Applicant Mobile Number (2nd App)
Gather if not in client file already
Applicant Email Address (2nd App)
Gather if not in client file already
Employment Status (2nd App)
Occupation / Job Title (2nd App) *
Example: Science or Engineering Degree
Self-Employed? (2nd App) *
Nature of work/business (2nd App) *
Applicant Address:

Physical Location of Home (map it) *

	Address
Street
City
State
Zip

Address Type *

General Policy Information:
Describe your Home *
How will this home be used? *
How is this Condo/Town Home be used *
How is this Manufactured/Mobile Home used *
Underwriting Questions:
Is there a Basement *
Total # of Floors (including Basement)
What is the construction type
What is the dwelling Foundation Type
Underwriting Questions specific to Manufactured/Mobile Home:
Year Built / Model *
What is the Length *
(In Feet)
What is the Width *
(In Feet)
What is the Type (Wide) *
Located On (Storage) *
Spaces in a Park *
Who owns the Land *
Reconstruction Cost Info (Optional):
Complete Hide
The following information is not required from the client since all carriers require that we run a cost estimator. However you may want to collect this info for the following reasons.

A. If the client is very detailed and wants to give this information then we can obtain it now.

B. If you are an agent that is very detailed about reconstruction cost and want to come as close as possible to the true replacement cost
of the home.
Year Built (FID-285) *
Square Footage of Living Area (FID-288) *
# of Acreage/Lot size *
Number of Stories *
Number of Fireplaces *
1-# of Chimneys (FID-300)
1-# of Pre-fab (FID-302)
# of Exterior Features *
Exterior Features #1 *
Exterior Features #2 *
Exterior Features #3 *
Exterior Features #4 *
What is the Construction Type *
Exterior Walls *
Garage & Carports *
# of Additional Attached Structures *
Attached Structures #1 *
Size in sq ft *
Attached Structures #2 *
Size in sq ft *
Attached Structures #3 *
Size in sq ft *
Attached Structures #4 *
Size in sq ft *
Total # of Kitchens *
Grade of Kitchen #1 *
Grade of Kitchen #2 *
Grade of Kitchen #3 *
Grade of Kitchen #4 *
Total # of Full Bathrooms *
Grade of Full Bathroom #1 *
Grade of Full Bathroom #2 *
Grade of Full Bathroom #3 *
Grade of Full Bathroom #4 *
Grade of Full Bathroom #5 *
Grade of Full Bathroom #6 *
Grade of Full Bathroom #7 *
Grade of Full Bathroom #8 *
Total # of 1/2 Bathrooms *
Grade of 1/2 Bathroom #1 *
Grade of 1/2 Bathroom #2 *
Grade of 1/2 Bathroom #3 *
Grade of 1/2 Bathroom #4 *
Grade of 1/2 Bathroom #5 *
Grade of 1/2 Bathroom #6 *
Grade of 1/2 Bathroom #7 *
Grade of 1/2 Bathroom #8 *
Air Conditioning *
Floor Finishes *
# of Split/Multiple Types *
Floor Finishes #1 *
Floor Finishes #2 *
Floor Finishes #3 *
Wall Finishes *
# of Split/Multiple Types *
Wall Finishes #1 *
Wall Finishes #2 *
Wall Finishes #3 *
# of Indoor Features *
Indoor Features #1 *
Size in sq ft *
Indoor Features #2 *
Size in sq ft *
Indoor Features #3 *
Size in sq ft *
Indoor Features #4 *
Size in sq ft *
Policy Coverage:
Show Hide
The following information is not required from the client since we automatically include all the standard coverages available on the policies and we will provide a proposal that explains all the coverage options and limits in detail. However you may want to go over the specifics for following reasons.

A. If the client is very detailed and wants to match coverage from a prior policy or wants specific limits on certain line of coverage.

B. If you are an agent that prefer to review/explain the coverage prior to the release of an actual proposal to determine what the client is looking for.
Dwelling Coverage Amount (FID-90) *
Cost per Square Foot *
txt
Cov. A with Extended Replacement (FID-287) *
Extended Replacement Cost (FID-106) *
Choose None if condo/townhome
txt
Detached Structure (FID-92) *
txt
Personal Property (FID-94) *
txt
Loss of Use (FID-96) *
txt
Loss of Rents *
txt
Ordinance of Law Coverage *
Condo Coverage
Dwelling Coverage Amount (FID-90) *
will be calculated by carrier system
Dwelling Coverage Specific Limit (FID-90) *
Personal Property (FID-94) *
will be calculated by carrier system
Personal Property Specific Limit (FID-94) *
Condo-Loss of Use (FID-96) *
will be calculated by carrier system
Loss of Use Specific Limit (FID-96) *
Loss of Rents/Fair Rental Value *
will be calculated by carrier system
Loss of Rents Specific Limit *
Loss Assessment *
will be calculated by carrier system
Loss Assessment Specific Limit *
Policy Deductible:
Deductible Options *
Attachments: (Optional)

Upload a File
Copy of prior policy or prior declarations, etc Cancel of
Notes:
Collect Quote info another LOB *

Auto Home (HO3) Renters (HO4) Condo (HO6) Landlord (DP3) Boat Flood RV Motorcycle Umbrella Vacant Land PAF No Other LOB (transfer to CPA now) No Other LOB (send to LSI Quoting Team)
Are you ready to send to CPA and validate *

Yes No
Now choose the CPA to help you find a market *

Earthquake for Primary Home CPA Earthquake for Secondary/Seasonal Home CPA Earthquake for Rental/Investment Home CPA Earthquake for Renters/Contents CPA Earthquake for Primary Condo/Townhome CPA Earthquake for Secondary Condo/Townhome CPA Earthquake for Tenant Occupied Condo/Townhome CPA Earthquake for Primary Manufactured/Mobile Home CPA Earthquake for Secondary Manufactured/Mobile Home CPA Earthquake for Tenant Occupied Manufactured/Mobile Home CPA Earthquake for Vacant Manufactured/Mobile Home CPA Earthquake for Vacant Home CPA Earthquake for Course of Constructions CPA None (do not proceed to CPA)
* If you want to send to LSI Quoting Team to do the CPA do not answer the 2nd question or select "None (do not proceed to CPA)" then select "No Other LOB (send to LSI Quoting Team)" on the first question.
* This will transfer the client info to another quote form to save time. Example - if a client calls for an auto quote but also wants a home quote. Then you can transfer the data to the home quote form and eliminate typing the same information multiple times
Should be Empty: