Renewal Questionnaire – Purely Insurance

Purely Renewal Questionnaire

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EZLynxAppID
Your Information

First Name*
Last Name*
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Email
Mobile Phone
Are you a Member of Costco or AAA?*
- Costco
- AAA
- None of the Above
Select Insurance Policies to update

Select Insurance Policies*
Personal Auto Odometer Verification
Current odometer readings directly affect your rates. Please take a minute to update.

How many autos are on your policy?*
Auto #1
Auto Make/Model #1
Auto Current Odometer Reading #1
Please upload a photo of Auto #1 odometer reading at the bottom of this form. If it is easier for you, you can send them by text or email.
Auto #2
Auto Make/Model #2
Auto Current Odometer Reading #2
Please upload a photo of Auto #2 odometer reading at the bottom of this form. If it is easier for you, you can send them by text or email.
Auto #3
Auto Make/Model #3
Auto Current Odometer Reading #3
Please upload a photo of Auto #3 odometer reading at the bottom of this form. If it is easier for you, you can send them by text or email.
Auto #4
Auto Make/Model #4
Auto Current Odometer Reading #4
Please upload a photo of Auto #4 odometer reading at the bottom of this form. If it is easier for you, you can send them by text or email.
Auto #5
Auto Make/Model #5
Auto Current Odometer Reading #5
Please upload a photo of Auto #5 odometer reading at the bottom of this form. If it is easier for you, you can send them by text or email.
Auto #6
Auto Make/Model #6
Auto Current Odometer Reading #6
Please upload a photo of Auto #6 odometer reading at the bottom of this form. If it is easier for you, you can send them by text or email.
Employment or School

Has there been any changes in employment or school status?*
Number of Drivers to Update:*
Driver #1

Driver Name:*
Enter Occupation Type/Retired/Unemployed*
If you are Retired or Unemployed type that.
Employer Name*
If you are Retired or Unemployed type that.
Employer Address*
Street Address Address Line 2 City State ZIP Code

If you are Retired or Unemployed use home address.
How many miles do you travel one way to work?*
If you are Retired or Unemployed use Zero.
How many days of the week do you drive?*
Driver #2

Driver Name:*
Enter Occupation Type/Retired/Unemployed*
If you are Retired or Unemployed type that.
Employer Name*
If you are Retired or Unemployed type that.
Employer Address*
Street Address Address Line 2 City State ZIP Code

If you are Retired or Unemployed use home address.
How many miles do you travel one way to work?*
If you are Retired or Unemployed use Zero.
How many days of the week do you drive?*
Driver #3

Driver Name:*
Enter Occupation Type/Retired/Unemployed*
If you are Retired or Unemployed type that.
Employer Name*
If you are Retired or Unemployed type that.
Employer Address*
Street Address Address Line 2 City State ZIP Code

If you are Retired or Unemployed use home address.
How many miles do you travel one way to work?*
If you are Retired or Unemployed use Zero.
How many days of the week do you drive?*
Driver #4

Driver Name:*
Enter Occupation Type/Retired/Unemployed*
If you are Retired or Unemployed type that.
Employer Name*
If you are Retired or Unemployed type that.
Employer Address*
Street Address Address Line 2 City State ZIP Code

If you are Retired or Unemployed use home address.
How many miles do you travel one way to work?*
If you are Retired or Unemployed use Zero.
How many days of the week do you drive?*
Driver #5

Driver Name:*
Enter Occupation Type/Retired/Unemployed*
If you are Retired or Unemployed type that.
Employer Name*
If you are Retired or Unemployed type that.
Employer Address*
Street Address Address Line 2 City State ZIP Code

If you are Retired or Unemployed use home address.
How many miles do you travel one way to work?*
If you are Retired or Unemployed use Zero.
How many days of the week do you drive?*
Driver #6

Driver Name:*
Enter Occupation Type/Retired/Unemployed*
If you are Retired or Unemployed type that.
Employer Name*
If you are Retired or Unemployed type that.
Employer Address*
Street Address Address Line 2 City State ZIP Code

If you are Retired or Unemployed use home address.
How many miles do you travel one way to work?*
If you are Retired or Unemployed use Zero.
How many days of the week do you drive?*
Education

Does anyone on the policy have a 4-year college degree?*
Number of Drivers:*
Driver #1

Driver Name:*
Degree Type:*
Driver #2

Driver Name:*
Degree Type:*
Driver #3

Driver Name:*
Degree Type:*
Driver #4

Driver Name:*
Degree Type:*
Driver #5

Driver Name:*
Degree Type:*
Driver #6

Driver Name:*
Degree Type:*
Young Drivers

Do you have young drivers that are eligible for the Good Student Discount (12 units or more with a 3.0 or above)?*
Number of Drivers:*
Driver #1

Driver Name:*
Driver #2

Driver Name:*
Driver #3

Driver Name:*
Driver #4

Driver Name:*
Driver #5

Driver Name:*
Driver #6

Driver Name:*
Aftermarket Equipment

Do you have any valuable aftermarket equipment installed on your auto?*
Describe your aftermarket equipment:*
Home Section

Has your Mortgage Company changed within the year?*
- Yes
- No
New Mortgage Company Name
New Mortgage Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Property Location Street Address
Vesting (I.E.: Bob and Suzy Smith as Joint Tenants):
Loan Number:
Do you have an Impound Account (Mortgagee Company Pays Insurance)?
Would you like us to send them a copy now?
New Mortgage Company Email (Required if you would like us to email them a copy):
New Mortgage Fax Number (Required if you would like us to fax them a copy):
Have there been any updates to your home in the last year?*
Select any updates below:*
List the update types per the selection above.*
Do you have Solar?*
How many solar panels?*
Are the solar panels owned or leased?*
What was the cost of the solar panels?*
Do you have any Jewelry or Fine Art items that need to be scheduled?*
***We’ll call you to discuss further.
How many members of your household are there?*
Household Member #1

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Household Member #2

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Household Member #3

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Household Member #4

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Household Member #5

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Household Member #6

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Household Member #7

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Household Member #8

Name:*
Date of Birth:*
Month
Day
Year
What is their relationship to you?*
Remodeling

Have you done any remodeling, including a pool or spa?*
Describe the scope of the remodeling:*
Security and Protection

Do you pay for a central burglar and/or fire alarm system?*
***Please upload the certificate or last invoice in the File Uploader at the bottom of this form.
Occupancy

Do you still occupy this property?*
Describe reason that you no longer occupy the property
Earthquake Coverage

Do you have Earthquake Coverage?*
Are you interested in an earthquake coverage quote?*
Umbrella Section

Have you acquired any additional risks that need to be added to your Umbrella policy?*
Rental Property Section

Have there been any updates to this property in the last year?*
Select any updates below:*
Describe the update types per the selection above.*
Do you have Solar?*
How many solar panels?*
Are the solar panels owned or leased?*
What was the cost of the solar panels?*
Remodeling
Have you done any remodeling, including a pool or spa?*
Describe the scope of the remodeling:*
Occupancy
Is this property still occupied?*
Describe reason for Vacancy and when it will be occupied
Mortgage Company Information
Has your Mortgage Company changed within the year?
New Mortgage Company Name
New Mortgage Company Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Property Location Street Address
Vesting (I.E.: Bob and Suzy Smith as Joint Tenants):
Loan Number:
Do you have an Impound Account (Mortgagee Company Pays Insurance)?
Would you like us to send them a copy now?
New Mortgage Company Email (Required if you would like us to email them a copy):
New Mortgage Fax Number (Required if you would like us to fax them a copy):
Earthquake Coverage

Do you have Earthquake Coverage?*
Are you interested in an earthquake coverage quote?*
Does your Tenant list you on their Renter's Policy?*
Umbrella Liability Insurance

Most people do not have enough liability coverage. Umbrella policies protect you when claims go above your policy limits and they are inexpensive. Would you like to review your policy limits to know if you have adequate protections?*
Please describe the asset(s) to be added:*
For example: Boat, RV, Motorcycle, or Rental Properties (incl. in another state).
Life Insurance

Do you feel that your Life Insurance needs to be evaluated?*
Complete Review

Our Complete Review is a service designed specifically for you to gain clarity in your real risks, understand how your current insurance plan will perform if the unthinkable happens, and know how to protect yourself.*
Please let me know any additional concerns, general questions, or future changes that you are aware of now.
Upload Documents

File Uploader
Upload any document(s) that we need for your requested change(s). Such as current odometer readings or last invoice for your burglar and/or fire alarm system.
Drop files here or

Max. file size: 128 MB.
I appreciate you taking the time to update your Insurance!

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ContactID
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ownerEmail

Purely Renewal Questionnaire

Your Information

Select Insurance Policies to update

Personal Auto Odometer Verification

Auto #1

Auto #2

Auto #3

Auto #4

Auto #5

Auto #6

Employment or School

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Education

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Young Drivers

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Aftermarket Equipment

Home Section

Household Member #1

Household Member #2

Household Member #3

Household Member #4

Household Member #5

Household Member #6

Household Member #7

Household Member #8

Remodeling

Security and Protection

Occupancy

Earthquake Coverage

Umbrella Section

Rental Property Section

Remodeling

Occupancy

Mortgage Company Information

Earthquake Coverage

Umbrella Liability Insurance

Life Insurance

Complete Review

Upload Documents