[Breathe – Bind It – Sully]

Breathe - Bind It - Sully

Required Extension Fields

Client Name*
EZLynxAppID*
Email*
Critical Same Day Bind Submission Cut Off Times:
• Monoline Policies – 4 p.m.
• Package Policies – 3 p.m.
Select Bind Request Type*
How many policies are you binding?
Evidence of Insurance & Other Policy Address Changes

If Property Policy, do you need an EOI sent to Lender?
Yes, please send EOI
You must put the Request for Evidence of Insurance in EZLynx!
Send Follow Up to Confirm New Address
10 Day Email to confirm Address Change on all Policies
30 Day Email to confirm Address Change on all Policies
Only use this for New Purchase when their mailing address needs to be changed on other policies.
Create Task to CS to apply Multi-Policy Discounts
Send Discount Audit Task to CS
This sends a Taks to CS to make sure Multi-Policy Discounts are applied to all policies correctly.
Policy 1

Policy Type
Insurance Company
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date*
MM slash DD slash YYYY
Mortgagee Billed
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date*
MM slash DD slash YYYY
How Many Autos on Policy?
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Other Type
Effective Date*
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Policy 2

Policy Type
Insurance Company
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date*
MM slash DD slash YYYY
Mortgagee Billed*
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date*
MM slash DD slash YYYY
How Many Autos on Policy?
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Other Type
Effective Date*
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Policy 3

Policy Type
Insurance Company
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date*
MM slash DD slash YYYY
Mortgagee Billed*
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date*
MM slash DD slash YYYY
How Many Autos on Policy?
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Mode of Payment*
Pay Plan
Authorized First Payment Amount
Other Type
Effective Date*
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Policy 4

Policy Type
Insurance Company
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date*
MM slash DD slash YYYY
Mortgagee Billed*
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date*
MM slash DD slash YYYY
How Many Autos on Policy
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Other Type
Effective Date
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Policy 5

Policy Type
Insurance Company
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date
MM slash DD slash YYYY
Mortgagee Billed*
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date
MM slash DD slash YYYY
How Many Autos on Policy?
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Other Type
Effective Date
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Policy 6

Policy Type
Insurance Company
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date
MM slash DD slash YYYY
Mortgagee Billed*
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date
MM slash DD slash YYYY
How Many Autos on Policy?
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Other Type
Effective Date*
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Policy 7

Policy Type
Insurance Company*
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date
MM slash DD slash YYYY
Mortgagee Billed*
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date
MM slash DD slash YYYY
How Many Autos on Policy?
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Mode of Payment*
Pay Plan
Authorized First Payment Amount
Other Type
Effective Date
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Policy 8

Policy Type
Insurance Company
Premium Sold*
Quote # (If Known)
Property (All Types)
Effective Date
MM slash DD slash YYYY
Mortgagee Billed*
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Vehicle Type
Effective Date
MM slash DD slash YYYY
How Many Autos on Policy?
Auto 1: Model
Auto 1: Odometer
Auto 2: Model
Auto 2: Odometer
Auto 3: Model
Auto 3: Odometer
Auto 4: Model
Auto 4: Odometer
Auto 5: Model
Auto 5: Odometer
Auto 6: Model
Auto 6: Odometer
Binding Instructions*
Pay Plan
Mode of Payment*
Authorized First Payment Amount
Other Type
Effective Date
MM slash DD slash YYYY
Binding Instructions*
Pay Plan
Mode of Payment
Authorized First Payment Amount
Down Payment Information

Down Payment Method
Do not enter payment if for a policy that is Mortgagee Billed.
Bank Account Number
Bank Routing Number
Draft Date
MM slash DD slash YYYY
Credit Card Number
Expiration Date
Security Code
Billing Zip Code
Recurring Payment Information

Recurring Payment Method
Bank Account Number
Routing Number
Draft Date
MM slash DD slash YYYY
Credit Card Number
Expiration Date
Security Code
Billing Zip Code
Instructions

Is Mailing Address different from Physical Address?*

Yes

No
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Do you need to send an Accord Loss Policy Release?*
For which policy or policies?
Send Applications By:*
Send to Client after Binding*
Bind Notes:
Upload Files for Binding

Upload Files

Drop files here or

Max. file size: 128 MB.
*
Bind It

Breathe - Bind It - Sully

Required Extension Fields

Evidence of Insurance & Other Policy Address Changes

Policy 1

Policy 2

Policy 3

Policy 4

Policy 5

Policy 6

Policy 7

Policy 8

Down Payment Information

Recurring Payment Information

Instructions

Upload Files for Binding