Dwelling Quote Form – Purely Insurance

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Purely Dwelling Quote Form

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EZLynxAppID
Your Information

Name*
First Last
Occupation*
Phone
Email*
General Questions

Is this a New Purchase*
- No
- New Purchase
- Refinance
Current Insurance Company
Type of Property*
- Primary Home
- Secondary Home
- Condo
- Townhome
- Rental Property
How many household members do you have?
Purchase Date
MM slash DD slash YYYY
Closing Date
MM slash DD slash YYYY
Property same as the primary address?*
- No
- Yes
Property Address
Street Address Address Line 2 City State ZIP Code
Property Information

Year Built
Full Bathrooms*
Three Quarter Bathrooms*
Half Bathrooms*
Kitchen Quality*
Basement Type*
Basement Walkout?
- Yes
- No
Basement Finished
Is there a sump pump?*
Is there a HOA or COOP?*
- NONE
- HOA
- Condo / Co-Op
Do you rent out this property?*
- No
- Short-Term (Airbnb, VRBO, etc)
- Long-Term (6+ month Lease)
Is the property located in a gated community?*
- Yes
- No
Is there a sprinkler system inside the property?*
- No
- Yes
Is there an actively monitored fire and/or burglar system?
- None
- Fire & Theft
- Fire Only
- Theft Only
Special Discounts possible for connected homes! Do you have any of the following?*
- None
- Smart Camera
- Smart Smoke Alarms
- Smart Lights
- Automatic Temperature Detector
- Water leakage/ automatic shut off
- Gas leakage detection/ automatic shut off
Is the property vacant or for sale?*
- No
- Yes
Does the Property have Solar Panels?*
Are Solar Panels owned or leased?
How many Solar Panels does the Property have?
Is there a trampoline?*
- No
- Yes
Does the Trampoline have a net aorund it?
Does this property have any of the following pool / hot tub features? (check all that apply)*
- NO Pool or Hot Tub
- Hot-Tub
- Pool
- Diving board
- Water Slide
Has the Roof been Updated?*
- Original
- Partial
- Complete
Roofing Material
Do you have any dogs?*
How many Dogs do you have?
Breed for Dog #1
Breed for Dog #2
Breed for Dog #3
Breed for Dog #4
Year Roof Updated
Hs the Furnace been Updated?*
- Original
- Partial
- Complete
Year Furnace Updated
Primary Heat Type
Is there a wood burning stove located in this property*
- Yes
- No
Has the A/C been updated?*
- Original
- Partial
- Complete
Year A/C Updated
Primary A/C Type
Has the Electrical been Updated?*
- Original
- Partial
- Complete
Year Electrical Updated
Electrical Updated
Has the Plumbing been Updated?*
- Original
- Partial
- Complete
Year Plumbing Updated
Plumbing Updated
Is there existing damage to the property?*
- No
- Yes
Provide details about existing damage
Have you had any claims in the past 5 years for this property?*
- No
- Yes
Provide details about the claim
Mortgage Information

Is this property owned by a Trust or LLC?*
- No
- Yes
Legal name of the Trust or LLC?
Is there a Mortgage on this property?*
- No
- Yes
Mortgage Company
Loan Number
Address
Street Address Address Line 2 City State ZIP Code
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Purely Dwelling Quote Form

Your Information

General Questions

Property Information

Mortgage Information

Do you have documents to upload?