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Home > Business > Business Auto
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Business Auto


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Industrial or Office Complex Lots Not Allowed
Full Legal Name of Business including any DBA *
First Name *
Last Name *
What is your TITLE with the company or tell us what your Relationship is to the company? *
Primary Phone Number *
E-Mail Address *
Mailing Address *
City *
State *
ZIP / Postal Code *
Number of Years in Business under Legal Name *
Business Type *




If Corporation or LLC, Federal ID# Required or if Sole Proprietor SSN Required *
Describe how the Business Auto(s) will be Used *
Will Vehicle be Garaged at the Mailing Address? *

If No, Where will Vehicle be Stored?
Do you operate an office at a location different from the mailing address? *

If Yes, Location of Office (Street Address):
City
State
Zip / Postal Code
Do you share your lot premises with another business? *

If yes, what business do you share your lot premises with? If no, type "NA." *
How Many Owners/Officers? *
Driver 1 Must be Owner
Driver 1 Legal Name as appears on License *
Date of Birth for Driver #1 *
Driver 1 License Number *
Driver 1 Any violations, accidents or claims in 3 years *

Driver 2 Owner or Non-owner? *

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" *


Driver 3 Owner or Non-owner? *

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" *


Driver 4 Owner or Non-owner? *

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" *


Do you employ additional drivers? If so, please send a list to dward@dwardins.com *

Anyone allowed to drive a vehicle home or after hours? *

If someone drives a vehicle home or after hours, list name or names. If no one drives a vehicle home or after hours, type "None" *
Do you currently have a Business Auto Liability Policy? *


Name of current Insurance Company or type None *
Has there been a lapse in coverage in the last 3 years? *

Has there been any claims in the past 36 months? *

What Liability Limit of Insurance do you want quoted? *
For the Owner - is there a personal insurance policy? *

If the owner has personal insurance, list the carrier's name. If the owner does not have personal insurance, type "NONE" *
PLEASE LET US KNOW
How did you hear about us? Please let us know *





If you selected "Other," tell us how you heard about us. *
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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