Repair Shops

REPAIR SHOP INFORMATION

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 *

Street Address of Repair Shop *

City *

State *

ZIP / Postal Code *

Type of Garage *

Auto Repair/Maintenance Shop
Body Shop
Combination Auto Repair & Body Shop

Is the Garage Operation located at a Home? *

YES
NO

Do You Own the Building? *

Approximate Age of Building *

Type of Construction *

Brick and Concrete Block
All Concrete Block
Frame
Frame with Brick
All Metal
Metal with Frame
All Other Construction

Approximate Sq. Footage of the garage-occupied area *

What Type of Coverage Would You Like Quoted? Select All that Apply

Garage Liability
Garagekeepers
Workers Compensation
Umbrella for Higher Limits
Shop Contents
Shop Building
Cyber Liability
Employment Practices Liability Insurance (EPLI)

How Many Bays are at your Shop? *

Where are the Vehicles Stored After Hours? *

What Type of Repair Work is Being Performed? *

What Type of Vehicles are you Working On? *

Any Major Engine Repairs? *

Yes
No

Any Frame Work Performed? *

Yes
No

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." *

Do you sell, rebuild, or repair autos with a salvage title? *

I do not work with salvaged vehicles
Yes, I work with salvaged vehicles

Do you perform mobile repair services? *

Yes
No

Do you have a tow truck? *

Yes
No

If you have a tow truck, do you tow for hire? *

Yes, I tow for hire
No, I only use the truck for my shop services
NA, I don't have a truck

How Many Owners/Officers? *

Any Inactive Officer(s) - List full name(s) or type "NA" *

Number of Full-Time Clerical Employees or type "None" *

Number of Part-Time Clerical Employees or type "None" *

Number of Mechanic(s) or type "None" *

Number of Non Employees 1099 or type "None" *

Mechanic #1 Full Name as Appears on License *

Mechanic #1 Date of Birth as Appears on License *

Mechanic #1 License Number and State *

Mechanic #1 Any violations, accidents or claims in 3 years *

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

Mechanic #2 Full Name as Appears on License or Type "NA" *

Mechanic #2 Date of Birth as Appears on License or Type "NA" *

Mechanic #2 License Number and State or type "NA" *

Mechanic #2 Any violations, accidents or claims in 3 years or select "NA" *

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

Mechanic #3 Full Name as Appears on License or Type "NA" *

Mechanic #3 Date of Birth as Appears on License or Type "NA" *

Mechanic #3 License Number and State or type "NA" *

Mechanic #3 Any violations, accidents or claims in 3 years or select "NA" *

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

Mechanic #4 Full Name as Appears on License or Type "NA" *

Mechanic #4 Date of Birth as Appears on License or Type "NA" *

Mechanic #4 License Number and State or type "NA" *

Mechanic #4 Any violations, accidents or claims in 3 years or select "NA" *

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

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

No
Yes

Do you sell vehicles or equipment? *

Yes
No

Do you allow customers to sell vehicles or equipment? *

Yes
No

Do you currently have a Garage Liability Policy? *

Yes, my garage has insurance
No

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 the Repair Shop had any claims in the past 36 months *

No claims in past 36 months
Yes there are claim(s)

What Liability Limit of Insurance do you want quoted? *

How did you hear about us? Please let us know *

Internet Search
Ga Indep Auto Dealer Assoc (GIADA)
Mailing from D. Ward
E-Learning Concepts Dealer Training
A Friend
Other

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.

ENTER VALIDATION CODE

For Security of your personal information, enter code and press submit

Auto
&
Home

Life
& Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Repair Shops

Contact Us Today!
770-974-0670

Resources

Contact Us

Auto & Home

Life & Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Repair Shops

Contact Us Today! 770-974-0670

Resources

Contact Us

Auto
&
Home

Life
& Disability

Contact Us Today!
770-974-0670