"*" indicates required fields

Step 1 of 22 - Insurance Type

Thank you for your interest in receiving a business insurance quote with Insuraserv Insurance Solutions. 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.

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

MM slash DD slash YYYY

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)

Employment Practices Liability (EPLI)

Property (Building coverage, contents, etc.)

Equipment Floater (Tools coverage, etc.)

Cyber Liability

Other

Other type of insurance*

Name*

First Last

Date of Birth*

YYYY

Email*

Mobile Phone*

Work Phone

Can we text you?*

Yes

Consent is not required as a condition of purchase. Message frequency will vary. Message and data rates may apply. Reply HELP for help or STOP to cancel. Privacy Policy.

Business Information

Business Name*

Entity Type*

FEIN*

Business Website

Is this business affiliated with a franchise?

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.

Maximum number of vehicles reached.

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

Yes

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?*

Yes

Do all drivers have a clean driving record?*

Yes

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 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

Do you lease your employees?*

Yes

Number of employees*

Estimated annual payroll*

Do you use any subcontractors? (1099s)*

Yes

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

Not yet

What year did the business start?*

Years of experience operating this business?*

Years of experience in this field?*

Building and Property Information

My business location is*

A business property or office

My home

This location is*

Leased

Owned

You may upload a copy of your lease here

Accepted file types: pdf, Max. file size: 12 MB.

PDF file type only.

Do you need coverage for the building?*

Yes

Have you made any tenant improvements?*

Yes

In the future

How much tenant improvement coverage do you need?

Square footage of your business*

Square footage of home office*

Security features. (Check all that apply)*

None

Smoke Detector

Fire Extinguisher

Deadbolts on all doors

Interior Fire Spinklers

Local Burglar Alarm

Local Fire Alarm

Central Station Burglar Alarm

Central Station Fire Alarm

Other

Other security features. (Please describe)

Do you have more than one business location?*

Yes

Additional Business Locations

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

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?*

Yes

I don't know

Year Roof Updated?

Year Plumbing Updated?

Year Electrical Updated?

Business Description

Please describe the nature of your business*

Customer Data

What type of customer data do you store?*

Do you store date from third parties?*

What security policies do you use?*

Which industry standards do you comply with?*

I don't know

PCI/DSS

NIST CSF

SOC 1/2

ISO 27001/2

ISO 8000/1

GDPR

HIPAA

FINRA

FDIC

HITECH

Other

None

Other industry standard*

Who manages you cybersecurity?*

Internal employee

External consultant

None

Do you encrypt all stored or accessed personal data?*

Yes

I don't know

How often do you backup your data*

Daily

Weekly

Monthly

Infrequently

None

I don't know

How long do you retain those backups?*

30 days or more

2 - 30 days

1 day or less

Manufacturing

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

Yes

Please describe

Claims Information

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

Yes

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

Current Insurance

Do you have ANY business insurance currently?*

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.

Liability Limits (Optional)

What is the Liability limit requested?

Do you need any Business Personal Property coverage?*

Yes

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

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

Owner and Employee List

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Use the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.

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

Private Passenger

Motorhomes

Motorcycles

Utility Trailers

Commercial Trucks

Commercial Trailers

Other

Other vehicles*

What is the total amount of coverage for other people's vehicles would you like?*

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?

None

New Parts

Used Parts

Exterior/Interior Trim

Apparel

Estimated annual over the counter sales

What are your security practices?*

3-Part Ticket

Key Cabinet

Protected Lot

None

Where do you store customer's vehicles?*

In Building

Fenced Area

Open Lot

Where do you store keys to customer's vehicles?*

Key Cabinet

In/On the Vehicle

Other

Please describe Other key storage location*

Do you tow for hire?*

Yes

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

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.)

Please describe Welding type of work performed*

Please describe Other type of work performed*

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

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?*

Yes

Yes: How much structural repair done?*

Additional Insured Information (Optional)

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

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: 12 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?*

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, we use 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. By submitting your information you acknowledge that an insurance agent with Insuraserv Insurance Solutions may contact you by phone, SMS, email, or mail to discuss and quote insurance for you or your business. To Unsubscribe from messaging reply STOP.

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

By submitting your information you acknowledge that an insurance agent with Insuraserv Insurance Solutions may contact you by phone, SMS, email, or mail to discuss and provide you with a quote. To Unsubscribe from messaging reply STOP.

Phone

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

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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Follow Us

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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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Follow Us

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