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Personal Automobile


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            770-974-0670  Office 

  • Multiple Carriers Will Compete
  • We'll Contact Same Business Day
  • DWard Insurance since 1988

Our Highly Rated Carriers: 

 Auto Owners * Travelers * Progressive * Utica * Mercury *

Safeco *  Main Street  *  Hartford * AARP * American Strategic * 


Submit the Below Quick Form



CONTACT INFORMATION
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Is primary phone number home, work or cell? *


E-Mail Address *
Date of Birth *
/ /
Marital Status *
License (State, Number) *
Do You Rent or Own Your Home? *

COVERAGE SELECTION
Bodily Injury Liability *
Property Damage Liability *
Uninsured Motorist Bodily Injury
Uninsured Motorist Property Damage
Medical Payments
Towing
Rental
DRIVERS INFORMATION
Driver 1
Driver 1 Legal Name as appears on License *
Driver 1 Date of Birth *
Driver 1 License Number *
Driver 1 Any violations, accidents or claims in 3 years *

If Yes to violations or claims during past 3yrs, Explain Here or Type NA: *
Driver 2 Legal Name as appears on License or type "NA" *
Driver 2 Date of Birth or type "NA" *
Driver 2 License Number or type "NA" *
Driver 2 Any violations, accidents or claims in 3 years or select "NA" *


If Yes to violations or claims during past 3yrs, Explain Here or Type NA: *
Driver 3 Name as appears on License or type "NA" *
Driver 3 Date of Birth or type "NA" *
Driver 3 License Number or type "NA" *
Driver 3 Any violations, accidents or claims in 3 years or select "NA" *


If Yes to violations or claims during past 3yrs, Explain Here or Type NA: *
Driver 4 Name as appears on License or type "NA" *
Driver 4 Date of Birth or type "NA" *
Driver 4 License Number or type "NA" *
Driver 4 Any violations, accidents or claims in 3 years or select "NA" *


If yes to violations or claims during past 3yrs, Explain Here or Type NA: *
Have all household residents whether full time or part time in your home been listed above on this application? *

VEHICLE(S) INFORMATION
Vehicle 1 Year Model *
Vehicle 1 Make and Model *
Vehicle 1 VIN *
Vehicle 1 - Comprehensive Deductible *




Vehicle 1 - Collision Deductible *




Driver of This Vehicle *
Drive Vehicle 1 to School or Work? *

How many miles will you drive your car annually (Approximately)? *
Vehicle #2
Is There A Second Vehicle? *

Vehicle 2 Year Model or Type "NA" *
Vehicle 2 Make and Model or Type "NA" *
Vehicle 2 VIN or Type "NA" *
Vehicle 2 - Comprehensive Deductible *





Vehicle 2 - Collision Deductible *





Driver of This Vehicle or Type "NA" *
Drive Vehicle 2 to School or Work? *


How many miles will you drive your car annually (Approximately)? If no car, type "NA" *
Vehicle #3
Is There A Third Vehicle? *

Vehicle 3 Year Model or Type "NA" *
Vehicle 3 Make and Model or Type "NA" *
Vehicle 3 VIN or Type "NA" *
Vehicle 3 - Comprehensive Deductible *





Vehicle 3 - Collision Deductible *





Driver of This Vehicle or Type "NA" *
Drive Vehicle 3 to School or Work? *


How many miles will you drive your car annually (Approximately)? If no car, type "NA" *
Vehicle #4
Is There A Fourth Vehicle? *

Vehicle 4 Year Model or Type "NA" *
Vehicle 4 Make and Model or Type "NA" *
Vehicle 4 VIN or Type "NA" *
Vehicle 4 - Comprehensive Deductible *





Vehicle 4 - Collision Deductible *





Driver of This Vehicle or Type "NA" *
Drive Vehicle 4 to School or Work? *


How many miles will you drive your car annually (Approximately)? If no car, type "NA" *
Do you have additional vehicles to be insured other than the 4 vehicles listed above? *

Other than Claims listed above, has an insurance company paid out any money for any reason on your policy during past 3 yrs? *


If you answered yes regarding other claims, please explain. If there are no other claims, type "NA." *
CURRENT INSURANCE INFORMATION
Do you currently have personal auto insurance? *

If yes, please provide name of current Insurance carrier. If no insurance, type "None." *
Any lapse in coverage during past 3 years? *
What is your current personal auto Insurance policy's expiration date? If no Insurance, type "NA." *
PLEASE LET US KNOW
How did you hear about us? Please let us know *





If you were referred to us by a friend, please provide their name. If you weren't referred by a friend, type "NA." *
Is there anything else that you would like for us to know concerning your up and coming Renewal?
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. *
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.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Mailing: 1720 Mars Hill Rd #8-185, Acworth, GA 30101
Physical: 3440 Blue Springs Road, #503j, Kennesaw, GA 30144

P: (770) 974-0670 | F: (770) 974-8577 |
E: dward@dwardins.com

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