Thank you for your interest in receiving a business insurance quote. This form should only take about 5-10 minutes to complete. Don't worry if you don't have everything. You can always click the "Save and continue later" button below. We'll email you a private link to pick up where you left off.

Which type of insurance are you looking for?*

Check all that apply.

Other type of insurance*

When do you want the policy, or policies, to start?*

Personal Information

Full Name*

Date of Birth*

Email*

Mobile Phone*

Can we text you?*

Yes

No

Work Phone

Business Information

Business Name*

Entity Type*

FEIN*

Business Website

Is this business affiliated with a franchise?

No

Yes

Business Address*

Street Address City State Zipcode

Business Owners

Number of Owners

Additional Owners*

(Click the "+" icon to add more owners)

First Name

Last Name

Date of Birth

Phone

% of Ownership

Vehicles

Year	Make	Model	VIN	Actions

There are no Vehicles.

Are all vehicles titled in the name of the business?*

Yes

No

Drivers

(Click the "+" icon to add more drivers)

First Name

Last Name

DOB (mm/dd/yyyy)

DL Number

DL State

Do any of your drivers take the vehicle(s) home at night?*

No

Yes

Do all drivers have a clean driving record?*

Yes

No

What is on each driver's record?

Include each driver's name and date of violation if possible.

Business Information Continued

What is your total annual gross sales / business income?*

What is your total annual gross commission?

Only for commission based businesses such as real estate, mortgage brokers, insurance agents, car dealerships, etc.

Do you have employee(s)?*

Yes

No

Do you lease your employees?*

No

Yes

Number of employees*

Estimated annual payroll*

Do you use any subcontractors? (1099s)*

Yes

No

How many subcontractors?*

Subcontractor annual payroll*

What type of work do your subs perform?*

Do you have a written contract with your subs requiring them to name your business as Additional Insured and show proof every year?*

Yes

No

Not yet

What year did the business start?*

Years of experience operating this business?*

Years of experience in this field?*

Additional Business Locations

Additional Location(s)

Please add all your additional business locations below.

Location	Stories	SqFt	Actions

There are no Locations.

Building Information

Year Built*

Number of stories of the building*

Construction Type*

Roof Type*

Other construction type*

Other roof type*

Has there been any updates to the roof, plumbing, or electrical?*

No

Yes

I don't know

Year Roof Updated?

Year Plumbing Updated?

Year Electrical Updated?

Business Description

Please describe the nature of your business*

Manufacturing

Is there any manufacturing, mixing, re-labeling, or repackaging of products?*

No

Yes

Please describe

Claims Information

Have you had any claims or losses in the last 5 years?*

No

Yes

What was the date, amount paid, and description of each loss or claim*

Current Insurance

Do you have ANY business insurance currently?*

No

Yes

Name of current insurance carrier?*

Expiration date of current policy*

Why are you looking for a new quote?

Current total insurance premium?

Current Policies

You may upload copies of your current policies here.

File types allowed: .pdf

Each file maximum size: 5MB

Maximum files: 10

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 10.

Liability Limits (Optional)

What is the Liability limit requested?

Do you need any Business Personal Property coverage?*

Yes

No

Not sure, let's discuss

How much Business Personal Property coverage do you want?

Are you interested in Loss of Use / Business Income coverage?*

Yes

No

Not sure, let's discuss

Garage & Dealers Owners and Employees List

This section requires the following information for all owners and employees: Name, Birthdate, Drivers License Number and License State, Employment Type (full or part time), and if the business provides the person with a vehicle.

How would you like to submit your owner(s) & employee(s) information?*

Continue online

I'll do this later

Employees List

First Name

Last Name

Date of Birth

Hire Date

We understand it may take some time to gather all this information. Please just be aware that we will need this information in order to submit to the insurance companies for a quote. Your agent will contact you to go over this.

Garage & Dealers Information

List the percentage of the work you provide for each section below.

Where work is performed. Total must equal 100%.

Percent of work performed at Your Shop

% at Your Shop

Percent of work performed at Customer's Location

% at Customer's Location

Percent of work performed at Other

% Other

0%

Please describe Other Location

Type(s) of work performed (in percent). Total must equal 100%.

Type of Work: Body/Paint

% Body/Paint

Type of Work: Brakes, Transmission or Suspension

% Brakes, Transmission or Suspension

Type of Work: Electrical

% Electrical

Type of Work: Mechanical

% Mechanical

Type of Work: Muffler/Radiator

% Muffler/Radiator

Type of Work: Oil Change

% Oil Change

Type of Work: Roadside Assistance

% Roadside Assistance

Type of Work: Safety Inspection

% Safety Inspection

Type of Work: Tires/Wheels

% Tires/Wheels

Type of Work: Tune Up

% Tune Up

Type of Work: Wash/Detail

% Wash/Detail

Type of Work: Welding

% Welding

Type of Work: Other

% Other (Upholstery, frame work, body work, window tint, windows, cleaning trailer, stereo system, etc.)

0%

Please describe Welding type of work performed*

Please describe Other type of work performed*

Do you provide any off-site services or mobile services?*

No

Yes

What is the maximum miles away from your business that you offer your services?*

Dealer Sales Questions

How many Dealer Plates do you have?*

Number of Repairer/Transporter plates owned by you?

Number of vehicles sold annually*

Number held for sale (Average #)*

Number held for sale (Maximum #)*

Number of vehicles sold on internet auction

Number of vehicles sold on consignment

Do you sell "salvage titled" vehicles?*

No

Yes

Yes: How much structural repair done?*

Additional Insured Information (Optional)

Do you have anyone that needs to be listed as Additional Insured?

No

Yes

Additional Insured Information. (i.e. Name & Address)

You may upload your additional insured documents using the upload field below.

Additional Insured Document(s)

You may upload up to 10 PDF documents. If you have more documents you can send them to your agent after they contact you.

Drop files here or

Accepted file types: pdf, Max. file size: 6 MB, Max. files: 10.

Additional Comments and/or Current Policy Upload (Optional)

If you have any additional comments, questions, or additional coverage required, please enter those here.

Any Additional Documents

You may upload up to 5 additional PDF documents here.

If a file is over 8MB please email to us at [email protected]

Drop files here or

Accepted file types: pdf, Max. file size: 8 MB, Max. files: 5.

Wrapping Up

What is the best time to call and discuss your quote?*

Please specify the best time to call*

Would you like a quote from a specific agent?

How were you referred to us?

Consent*

Like most insurance agencies, Culley Insurance Group uses information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

All the above information is accurate and true to the best of my knowledge.*

Yes

Would you like to create a user account to manage your submissions?*

Yes, create my account

Not at this time

Username*

Password*

Enter Password Confirm Password

Comments

This field is for validation purposes and should be left unchanged.

Personal Information

Business Information

Business Owners

Vehicles

Drivers

Business Information Continued

Building and Property Information

Additional Business Locations

Building Information

Business Description

Customer Data

Manufacturing

Claims Information

Current Insurance

Liability Limits (Optional)

Garage & Dealers Owners and Employees List

Garage & Dealers Information

Garage & Dealers Information

Dealer Sales Questions

Additional Insured Information (Optional)

Additional Comments and/or Current Policy Upload (Optional)

Wrapping Up

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Password

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