Personal Automobile

CONTACT INFORMATION
First Name Required
Last Name Required
Street Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
Primary Phone Number Required
Is primary phone number home, work or cell? Required	Home Work Cell
E-Mail Address Required
Date of Birth Required	January February March April May June July August September October November December / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Marital Status Required	Single Married Separated Divorced Widowed
License (State, Number) Required
Do You Rent or Own Your Home? Required	Rent Own
COVERAGE SELECTION
Bodily Injury Liability Required	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Property Damage Liability Required	$25,000 $50,000 $100,000 $250,000 $300,000
Uninsured Motorist Bodily Injury Optional	$10,000/$20,000 $20,000/$40,000 $25,000/$50,000 $30,000/$60,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Uninsured Motorist Property Damage Optional	$10,000 $15,000 $25,000 $50,000 $100,000 $250,000
Medical Payments Optional	$1,000 $5,000 $10,000 $25,000 $50,000
Towing Optional	Yes No
Rental Optional	Yes No
DRIVERS INFORMATION
Driver 1
Driver 1 Legal Name as appears on License Required
Driver 1 Date of Birth Required
Driver 1 License Number Required
Driver 1 Any violations, accidents or claims in 3 years Required	No known violation(s) for this driver Yes, this driver has violation(s)
If Yes to violations or claims during past 3yrs, Explain Here or Type NA: Required
Driver 2 Legal Name as appears on License or type "NA" Required
Driver 2 Date of Birth or type "NA" Required
Driver 2 License Number or type "NA" Required
Driver 2 Any violations, accidents or claims in 3 years or select "NA" Required	NA No known violation(s) for this driver Yes, this driver has violation(s)
If Yes to violations or claims during past 3yrs, Explain Here or Type NA: Required
Driver 3 Name as appears on License or type "NA" Required
Driver 3 Date of Birth or type "NA" Required
Driver 3 License Number or type "NA" Required
Driver 3 Any violations, accidents or claims in 3 years or select "NA" Required	NA No known violation(s) for this driver Yes, this driver has violation(s)
If Yes to violations or claims during past 3yrs, Explain Here or Type NA: Required
Driver 4 Name as appears on License or type "NA" Required
Driver 4 Date of Birth or type "NA" Required
Driver 4 License Number or type "NA" Required
Driver 4 Any violations, accidents or claims in 3 years or select "NA" Required	NA No known violation(s) for this driver Yes, this driver has violation(s)
If yes to violations or claims during past 3yrs, Explain Here or Type NA: Required
Have all household residents whether full time or part time in your home been listed above on this application? Required	Yes No
VEHICLE(S) INFORMATION
Vehicle 1 Year Model Required	2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Vehicle 1 Make and Model Required
Vehicle 1 VIN Required
Vehicle 1 - Comprehensive Deductible Required	50 100 250 500 1000
Vehicle 1 - Collision Deductible Required	50 100 250 500 1000
Driver of This Vehicle Required
Drive Vehicle 1 to School or Work? Required	Yes No
How many miles will you drive your car annually (Approximately)? Required
Vehicle #2
Is There A Second Vehicle? Required	Yes No
Vehicle 2 Year Model or Type "NA" Required
Vehicle 2 Make and Model or Type "NA" Required
Vehicle 2 VIN or Type "NA" Required
Vehicle 2 - Comprehensive Deductible Required	NA50 100250 500100
Vehicle 2 - Collision Deductible Required	NA50 100250 5001000
Driver of This Vehicle or Type "NA" Required
Drive Vehicle 2 to School or Work? Required	NA Yes No
How many miles will you drive your car annually (Approximately)? If no car, type "NA" Required
Vehicle #3
Is There A Third Vehicle? Required	Yes No
Vehicle 3 Year Model or Type "NA" Required
Vehicle 3 Make and Model or Type "NA" Required
Vehicle 3 VIN or Type "NA" Required
Vehicle 3 - Comprehensive Deductible Required	NA50 100250 5001000
Vehicle 3 - Collision Deductible Required	NA50 100250 5001000
Driver of This Vehicle or Type "NA" Required
Drive Vehicle 3 to School or Work? Required	NA Yes No
How many miles will you drive your car annually (Approximately)? If no car, type "NA" Required
Vehicle #4
Is There A Fourth Vehicle? Required	Yes No
Vehicle 4 Year Model or Type "NA" Required
Vehicle 4 Make and Model or Type "NA" Required
Vehicle 4 VIN or Type "NA" Required
Vehicle 4 - Comprehensive Deductible Required	NA50 100250 5001000
Vehicle 4 - Collision Deductible Required	NA50 100250 5001000
Driver of This Vehicle or Type "NA" Required
Drive Vehicle 4 to School or Work? Required	NA Yes No
How many miles will you drive your car annually (Approximately)? If no car, type "NA" Required
Do you have additional vehicles to be insured other than the 4 vehicles listed above? Required	Yes No
Other than Claims listed above, has an insurance company paid out any money for any reason on your policy during past 3 yrs? Required	Not Sure Yes, other claims were paid out No, any claim is listed above for the driver
If you answered yes regarding other claims, please explain. If there are no other claims, type "NA." Required
CURRENT INSURANCE INFORMATION
Do you currently have personal auto insurance? Required	Yes No
If yes, please provide name of current Insurance carrier. If no insurance, type "None." Required
Any lapse in coverage during past 3 years? Required
What is your current personal auto Insurance policy's expiration date? If no Insurance, type "NA." Required
PLEASE LET US KNOW
How did you hear about us? Please let us know Required	Internet SearchGa Indep Auto Dealer Assoc (GIADA) Mailing from D. WardE-Learning Concepts Dealer Training A FriendOther
If you were referred to us by a friend, please provide their name. If you weren't referred by a friend, type "NA." Required
Is there anything else that you would like for us to know concerning your quote request? Optional
SIGNATURE REQUIRED
I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage.
By typing my name warrants my signature. Required
ADDITIONAL INFORMATION NEEDED
After you have sumitted your quote request, we will start working on your quote and we will help assist with obtaining your claim history. The insurance carriers require us to show prior proof of coverage along with claim history.
Thank you for your time and we will be in touch with you today unless this is after hours or on the weekend.
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

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