Thank you for your interest in receiving a homeowners quote. This form should only take about 7-10 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.

Date you want this policy to start*

Name*

First Name Last Name

Mobile Phone*

Can we text you?*

Yes

No

Work Phone

Email*

Date of Birth*

Occupation*

Please specify other occupation

Personal Information

Marital Status*

Children in household (under 18)

Spouse / Partner's Name*

First Last

Spouse / Partner's Date of Birth*

Spouse / Partner's Phone

Spouse / Partner's Email

Spouse / Partner's Occupation

Please specify other occupation

Property Information

Year Home Built*

Construction Type*

Exterior Walls*

Number of Stories*

Is there an Ohana on the property?*

Yes

No

Ohana is*

Attached

Detached

Ohana Usage*

Roofing Material*

Roof Design*

Roof Hurricane Clips / Straps*

Does the property have hurricane impact resistant glass?*

Does the roof have any solar panels?*

Yes

No

How many solar panels*

Current value of solar panels*

Do you know when the roof, plumbing, electrical, or exterior paint was updated?*

No

Yes

I don't know

Year Roof Updated*

Year plumbing updated*

Year electrical updated*

Year ext. paint updated*

Purchase Date*

Purchase Price*

Replacement Cost

We need this information to determine how much it would cost to rebuild this property in the event of a loss.

Has the electrical or plumbing on your condo been updated? If so what year(s)?*

Foundation Type*

Square Feet*

Basement?*

Yes

No

Sq Ft of Basement

% Basement Finished

Garage*

What type of other garage does the property have?*

Full Baths*

Half Baths*

Bathroom Grade*

Kitchen Grade*

Cooling / Air*

Primary Heat Source*

Fireplace Types*

None

Wood burning fireplace

Gas fireplace

Wood stove

How many of each type of fireplace?

Deck / Lanai

Deck / Lanai Sq Ft*

Upload Current Policy

To better assist us in comparing your current coverage to our proposal, please upload a copy of your current homeowners policy.

Would you like to upload a copy of your current homeowners policy?*

Yes

No

Name of current insurance carrier*

Why we need this: We represent many different carriers and we don't want to quote your insurance with the same carrier.

When does your current policy expire?

Current Policy Upload*

You may upload up to 10 policy documents. Only .pdf file types accepted.

Drop files here or

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

Claims and Rating Information

Liability Limit

Dwelling / Improvements Coverage*

Contents Coverage Amount*

Loss of Use Amount*

Reported Claims (last 3 years)*

Have you had any insurance lapse (30 days or more), cancel, or non-renew in the last 3 years?*

No

Yes

No prior insurance

Optional Discounts

The following discounts are available. Please check all that apply.

Please let us know what unique features this property has (ie. elevator, backup generator, server room, etc.)

Scheduled Items

Most homeowners policies have limitations on the following types of personal property. You have the option to schedule (or add) these special items to your policy for higher coverage.

Examples of these types of items include: jewelry, furs, art, collectibles, cameras, computers, golfing equipment, guns, antiques, silverware, bicycles, coins, musical instruments.

Do you have any items you would like to schedule?*

No

Yes

Please describe your items

Last Step

You're almost done!

Would you like to receive an auto quote as well to maximize your savings?*

Yes

No

Let's discuss

Would you like a quote from a specific agent?

How were you referred to us?

Is there anything you want us to know?

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?*

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Email

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Get a Home Insurance Quote

Personal Information

Property Information

Property Information

Replacement Cost

Upload Current Policy

Claims and Rating Information

Optional Discounts

More Property Info

Scheduled Items

Last Step

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