Business Auto

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 *

Corporation
Sole Proprietor
Partnership
LLC
Other

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? *

Yes
No

If No, Where will Vehicle be Stored?

Do you operate an office at a location different from the mailing address? *

Yes
No

If Yes, Location of Office (Street Address):

City

State

Zip / Postal Code

Do you share your lot premises with another business? *

Yes
No

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 *

No known violation(s) for this driver
Yes, this driver has violation(s)

Driver 2 Owner or Non-owner? *

Owner
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" *

NA
No known violation(s) for this driver
Yes, this driver has violation(s)

Driver 3 Owner or Non-owner? *

Owner
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" *

NA
No known violation(s) for this driver
Yes, this driver has violation(s)

Driver 4 Owner or Non-owner? *

Owner
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" *

NA
No known violation(s) for this driver
Yes, this driver has violation(s)

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

No
Yes

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

Yes
No

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? *

Yes
No
I had a policy but it lapsed

Name of current Insurance Company or type None *

Has there been a lapse in coverage in the last 3 years? *

No, there has not been a lapse in coverage.
Yes, there has been a lapse in coverage.

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

No Claims during past 36 months
Yes there are claim(s)

What Liability Limit of Insurance do you want quoted? *

For the Owner - is there a personal insurance policy? *

Yes, the owner has a personal insurance policy
No, the owner does not have personal insurance

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 *

Internet SearchGa Indep Auto Dealer Assoc (GIADA)
Mailing from D. WardE-Learning Concepts Dealer Training
A FriendOther

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 quote request?

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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Auto
&
Home

Life
& Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Business Auto

Contact Us Today!
770-974-0670

Resources

Contact Us

Auto & Home

Life & Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Business Auto

Contact Us Today! 770-974-0670

Resources

Contact Us

Auto
&
Home

Life
& Disability

Contact Us Today!
770-974-0670