Thank you for your interest in receiving a business insurance quote with First Choice Insurance Group. 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.
- General Liability
- Workers Comp
- Commercial Auto
- Garage & Dealers Policy
- Professional Liability (E&O)
- Property (Building coverage, contents, etc.)
- Equipment Floater (Tools coverage, etc.)
- Cyber Liability
- Other
Other type of insurance*
When do you want the policy, or policies, to start?*
MM slash DD slash YYYY

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Personal Information
Full Name*
First Last
Date of Birth*
Email*
Mobile Phone*
Work Phone

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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

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Business Owners
Number of Owners
Additional Owners*
(Click the "+" icon to add more owners)
First Name Last Name Date of Birth Phone Email % of Ownership

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Vehicles

Vehicles

Year	Make	Model	VIN	Actions
				Edit Delete
There are no Vehicles.

Maximum number of vehicles reached.

Are all vehicles titled in the name of the business?*
- Yes
- No

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Drivers
Drivers
(Click the "+" icon to add more drivers)
Driver 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.

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Business Information Continued
What is your total annual sales? (Gross)*
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?*

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Additional Business Locations
For each additional location please list the Address, Number of Stories, and Square Footage you occupy.*

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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?

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Business Description
Please describe the nature of your business*

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Manufacturing
Is there any manufacturing, mixing, re-labeling, or repackaging of products?*
- No
- Yes
Please describe

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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*

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Current Insurance
Do you have ANY business insurance currently?*
- No
- Yes
Name of current insurance carrier?*
Expiration date of current policy*
Month
Day
Year
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.

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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

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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
Owner and Employee List
Actions
Edit

Delete
There are no People.
Maximum number of people reached.
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.

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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?*

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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?*

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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.

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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 admin@culleygrp.com
Drop files here or

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

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Wrapping Up
What is the best time to call and discuss your quote?*
- Morning
- Afternoon
- Evening
- Anytime
- Other
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, [agencyname] 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

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Comments
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Step 1 of 23 - Insurance Type

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

Username
Password

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First Name	Last Name	Date of Birth	Phone	Email	% of Ownership

Driver Name	DOB (mm/dd/yyyy)	DL Number	DL State