Umbrella Ins. Purl

Umbrella Ins. Purl

This Umbrella 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 Names (LSI) *
Producer Names (Rouland) *
Producer Names (HRC) *
Producer Names (JCI) *
Producer Names (Elite One) *
For Edit Submission
If known otherwise type Unknown
Date *

Month Day Year
Date
Quote Start Time: *

: Hour Minutes AM/PM Option
How did you hear about us? *
Referred by: *
If known otherwise type Unknown
Notes:
First Applicant:
First & Last Name: *
as listed on driver license
Applicant Home Number:
Gather if not in client file already
Applicant Mobile Number:
Gather if not in client file already
Applicant Email Address:
Gather if not in client file already
Birthdate *
Date
Gender: *
Marital Status: *
Employment Status: *
Occupation / Job Title *
Example: Science or Engineering Degree
Self-Employed? *
Nature of work/business *
Second Applicant:
First & Last Name: *
as listed on driver license
Applicant Home Number:
Gather if not in client file already
Applicant Mobile Number:
Gather if not in client file already
Applicant Email Address:
Gather if not in client file already
Birthdate *
Date
Gender: *
Employment Status: *
Occupation / Job Title *
Example: Science or Engineering Degree
Self-Employed? *
Nature of work/business *
Applicant Address:

Physical Location of Home (map it)

	Address
Street
City
State
Zip

Address Type *

Personal Property Exposures:
Describe your Primary Home: *
Primary Home Address (map it) *
Do you have a Second Vacation/Seasonal Home: *
Second Vacation/Seasonal Home Address (map it) *
Any Rental Property to be covered by Umbrella? *
How many Rental Properties will be added? *
Describe 1st Rental Property *
1st Rental Property Address (map it) *
Describe 2nd Rental Property *
2nd Rental Property Address (map it) *
Describe 3rd Rental Property *
3rd Rental Property Address (map it) *
Describe 4th Rental Property *
4th Rental Property Address (map it) *
Describe 5th Rental Property *
5th Rental Property Address (map it) *
Describe 6th Rental Property *
6th Rental Property Address (map it) *
Describe 7th Rental Property *
7th Rental Property Address (map it) *
Describe 8th Rental Property *
8th Rental Property Address (map it) *
Describe 9th Rental Property *
9th Rental Property Address (map it) *
Describe 10th Rental Property *
10th Rental Property Address (map it) *
Rental Property Questions:
Are any of the rentals properties public funded (includes Sec 8, HUD, Institutional), or used as student housing? *
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? *
Please explain *
Does any of the rental properties have security bars on the windows? *
Does the security bars have a built in quick release mechanism? *
Are any of the rentals written by a surplus lines/non-admitted carrier or The California Fair Plan? *
Please explain *
Does the client own any rural vacant land? *
Number of Acres *
Does the client own any urban vacant land? *
Number of Lots *
Personal Vehicle Exposures:
Number of Personal Automobiles *
Liability Limit of Personal Automobiles *
Number of Drivers Covered by Umbrella *
Applicant 1 and 2 are considered driver 1 and 2
Driver #1:
First & Last Name *
Relationship *
Gender *
Martial Status *
DOB *
Driver License Number *
DL State *
Driver #2:
First & Last Name *
Relationship *
Gender *
Martial Status *
DOB *
Driver License Number *
DL State *
Driver #3:
First & Last Name *
Relationship *
Gender *
Martial Status *
DOB *
Driver License Number *
DL State *
Driver #4:
First & Last Name *
Relationship *
Gender *
Martial Status *
DOB *
Driver License Number *
DL State *
Driver #5:
First & Last Name *
Relationship *
Gender *
Martial Status *
DOB *
Driver License Number *
DL State *
Number of Personal Motorcycles *
Liability Limit of Personal Motorcycles *
Number of Personal Motor Homes *
Liability Limit of Motor Home *
Watercraft/Boat Exposures:
Number of Boats *
Liability Limit of Boats *
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 *
Liability Limit of Jetski *
Unlicensed Vehicle Exposures (includes off-road motorcycles, atv, snowmobiles or other unlicensed vehicle)
Number of Unlicensed Vehicle *
Liability Limit of Unlicensed Vehicle *
Describe *
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) Flood Boat Earthquake RV Motorcycle 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 *

Umbrella 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: