Business Auto

Industrial or Office Complex Lots Not Allowed
Full Legal Name of Business including any DBA Required
First Name Required
Last Name Required
What is your TITLE with the company or tell us what your Relationship is to the company? Required
Primary Phone Number Required
E-Mail Address Required
Mailing Address Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
Number of Years in Business under Legal Name Required
Business Type Required	Corporation Sole Proprietor Partnership LLC Other
If Corporation or LLC, Federal ID# Required or if Sole Proprietor SSN Required Required
Describe how the Business Auto(s) will be Used Required
Will Vehicle be Garaged at the Mailing Address? Required	Yes No
If No, Where will Vehicle be Stored? Optional
Do you operate an office at a location different from the mailing address? Required	Yes No
If Yes, Location of Office (Street Address): Optional
City Optional
State Optional
Zip / Postal Code Optional
Do you share your lot premises with another business? Required	Yes No
If yes, what business do you share your lot premises with? If no, type "NA." Required
How Many Owners/Officers? Required
Driver 1 Must be Owner
Driver 1 Legal Name as appears on License Required
Date of Birth for Driver #1 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)
Driver 2 Owner or Non-owner? Required	Owner Non-owner
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)
Driver 3 Owner or Non-owner? Required	Owner Non-owner
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)
Driver 4 Owner or Non-owner? Required	Owner Non-owner
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)
Do you employ additional drivers? If so, please send a list to dward@dwardins.com Required	No Yes
Anyone allowed to drive a vehicle home or after hours? Required	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" Required
Do you currently have a Business Auto Liability Policy? Required	Yes No I had a policy but it lapsed
Name of current Insurance Company or type None Required
Has there been a lapse in coverage in the last 3 years? Required	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? Required	No Claims during past 36 months Yes there are claim(s)
What Liability Limit of Insurance do you want quoted? Required	State Minimum to get started $300,000 $500,000 $1,000,000 Quote Umbrella
For the Owner - is there a personal insurance policy? Required	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" 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 selected "Other," tell us how you heard about us. 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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