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Business Insurance Quote

Home/Business Insurance Quote

"*" indicates required fields

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.

MM slash DD slash YYYY
Which type of insurance are you looking for?*
Check all that apply.
Primary Insured Name*
Date of Birth*
Can we text you?*

Business Information

If you do not have either, or operate using your Social Security Number, please enter "none".

If different than your legal business name above.
Is this business affiliated with a franchise?
Business Address*

This should be the physical address of your business. No PO Boxes please.

Mailing Address*

Business Owners

Second Owner

2. Owner Name*
2. Owner Date of Birth*

Third Owner

3. Owner Name*
3. Owner Date of Birth*

Fourth Owner

4. Owner Name*
4. Owner Date of Birth*

Vehicles

Are all vehicles titled in the name of the business?*
Are all vehicles stored at your business address?*

Vehicle 1

1. Permanently Attached Equipment*

Vehicle 2

2. Permanently Attached Equipment*

Vehicle 3

3. Permanently Attached Equipment*

Vehicle 4

4. Permanently Attached Equipment*

Vehicle 5

5. Permanently Attached Equipment*

Vehicle 6

6. Permanently Attached Equipment*

7+ Vehicles

Please enter the VIN, Year, Make, and Model of your additional vehicles.

Drivers

Excluding the primary insured
Do any of your drivers take the vehicle(s) home at night?*
Do all drivers have a clean driving record?*
Include each driver's name and date of violation if possible.

Driver 1

Driver 1: Name*
Driver 1. Date of Birth*

Driver 2

Driver 2: Name*
Driver 2. Date of Birth*

Driver 3

Driver 3: Name*
Driver 3. Date of Birth*

Driver 4

Driver 4: Name*
Driver 4. Date of Birth*

Driver 5

Driver 5: Name*
Driver 5. Date of Birth*

Driver 6

Driver 6: Name*
Driver 6. Date of Birth*

Driver 7

Driver 7: Name*
Driver 7. Date of Birth*

Driver 8

Driver 8: Name*
Driver 8. Date of Birth*

Drivers 9+

Please enter the Name, Date of Birth, Drivers License Number & State of your additional drivers

Business Information Continued

If you sell a product enter your total annual sales.

If you provide a service enter your total business income.

If you're business is new and you do not have any business income yet, please enter what you estimate your first year's sales/income will be.

Only for commission based businesses such as real estate, mortgage brokers, insurance agents, car dealerships, etc.
Do you have employee(s)?*
Do you lease your employees?*
Do you use any subcontractors? (1099s)*

This is how much you pay your subcontractors, gross, per year.

Example: For contractors this could include roofing, plumbing, electrical, foundation pouring, etc.

Example: For real estate brokers this would include your agents.

Example: For janitorial this could include other cleaners, landscapers, etc.

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

Building and Property Information

My business location is*
This location is*
Accepted file types: pdf, Max. file size: 6 MB.
PDF file type only.

Its best for us to review the lease to make sure the insurance quotes are in accordance with your lease requirements. (Some leases require the tenant to insure the glass in the building, name the landlord as Additional Insured, and will list the required liability limits)

Do you need coverage for the building?*
Have you made any tenant improvements?*

This would be upgrades to the inside of your unit such as flooring, walls, built-ins, etc.

This is your office space, not the total square footage of the building.

Security features. (Check all that apply)*
Do you have more than one business location?*

Additional Business Locations

Location 2 Address*
Add 3rd Location?
Location 3 Address
Add 4th Location?
Location 4 Address*

Building Information

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

If you are don't know when the roof was last updated just enter "unsure".

If you are don't know when the plumbing was last updated just enter "unsure".

If you are don't know when the electrical was last updated just enter "unsure".

Business Description

Customer Data

Examples include: Social security numbers, credit/debit cards, account number, health care records, personal information, etc.

• Acceptable Use Policy
• Backup & Retention Policy
• Data Security Policy
• Incident Response Policy
• Network Security Policy
• Risk Assessment & Management Policy
• SDLC & QA Policy
• Third Party Security Policy

If you don't have a security policy in place just enter "none".

Which industry standards do you comply with?*
Who manages you cybersecurity?*
Do you encrypt all stored or accessed personal data?*

This also includes information which is on mobile devices, transmitted wirelessly, or transmitted over public networks, and encryption of non-employee full Social Security and full credit card numbers.

How often do you backup your data*
How long do you retain those backups?*
Is there any manufacturing, mixing, re-labeling, or repackaging of products?*
Have you had any claims or losses in the last 5 years?*
Do you have ANY business insurance currently?*
Expiration date of current policy*
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)

    Do you need any Business Personal Property coverage?*

    Example: Office equipment, computers, furniture, tools (that stay at the business location), or other items used for your business.

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

    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 employee(s) information?*
    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

    What types of vehicles you service, repair, or sell?*
    Select all that apply
    Example: If you have 20 vehicles at any one time and each vehicle has an average value of $25,000 then you would want $500,000 in coverage.
    What parts and accessories do you sell over the counter?
    What are your security practices?*
    Where do you store customer's vehicles?*
    Where do you store keys to customer's vehicles?*
    Do you tow for hire?*

    Garage & Dealers Information

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

    Where work is performed. Total must equal 100%.
    % at Your Shop
    % at Customer's Location
    % Other

    0%

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

    % Body/Paint
    % Brakes, Transmission or Suspension
    % Electrical
    % Mechanical
    % Muffler/Radiator
    % Oil Change
    % Roadside Assistance
    % Safety Inspection
    % Tires/Wheels
    % Tune Up
    % Wash/Detail
    % Welding
    % Other (Upholstery, frame work, body work, window tint, windows, cleaning trailer, stereo system, etc.)

    0%

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

    Dealer Sales Questions

    Do you sell "salvage titled" vehicles?*

    Additional Insured Information (Optional)

    Do you have anyone that needs to be listed as Additional Insured?
    You may upload your additional insured documents using the upload field below.
    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)

      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?*
        Hidden
        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.
        All the above information is accurate and true to the best of my knowledge.*
        Would you like to create a user account to manage your submissions?*
        Password*
        This field is for validation purposes and should be left unchanged.

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        Locations

        • Maui, Hawaii
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        Culley Insurance GroupHawaii Mailing Address: PO Box 1827, Kihei HI, 96753 • (808) 419-7099
        Culley Insurance GroupOregon Mailing Address: PO Box 7258, Bend OR, 97708 • (541) 550-7075
        Fax: 808-879-2370
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