| REPAIR SHOP INFORMATION |
| Full Legal Name of Business including any DBA
Required
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| First Name
Required
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| Last Name
Required
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| What is your TITLE with the company or tell us what your Relationship is to the company?
Required
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| Primary Phone Number
Required
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| E-Mail Address
Required
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| Mailing Address
Required
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| City
Required
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| State
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| ZIP / Postal Code
Required
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| Number of Years in Business under Legal Name
Required
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| Business Type
Required
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| If Corporation or LLC, Federal ID# Required or if Sole Proprietor SSN Required
Required
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| Street Address of Repair Shop
Required
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| City
Required
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| State
Required
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| ZIP / Postal Code
Required
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| Type of Garage
Required
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| Is the Garage Operation located at a Home?
Required
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| Do You Own the Building?
Required
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| Approximate Age of Building
Required
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| Type of Construction
Required
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| Approximate Sq. Footage of the garage-occupied area
Required
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| What Type of Coverage Would You Like Quoted? Select All that Apply
Optional
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| How Many Bays are at your Shop?
Required
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| Where are the Vehicles Stored After Hours?
Required
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| What Type of Repair Work is Being Performed?
Required
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| What Type of Vehicles are you Working On?
Required
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| Any Major Engine Repairs?
Required
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| Any Frame Work Performed?
Required
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| Do you share your lot premises with another business?
Required
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| If yes, what business do you share your lot premises with? If no, type "NA."
Required
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| Do you sell, rebuild, or repair autos with a salvage title?
Required
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| Do you perform mobile repair services?
Required
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| Do you have a tow truck?
Required
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| If you have a tow truck, do you tow for hire?
Required
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| How Many Owners/Officers?
Required
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| Any Inactive Officer(s) - List full name(s) or type "NA"
Required
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| Number of Full-Time Clerical Employees or type "None"
Required
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| Number of Part-Time Clerical Employees or type "None"
Required
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| Number of Mechanic(s) or type "None"
Required
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| Number of Non Employees 1099 or type "None"
Required
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| Mechanic #1 Full Name as Appears on License
Required
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| Mechanic #1 Date of Birth as Appears on License
Required
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| Mechanic #1 License Number and State
Required
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| Mechanic #1 Any violations, accidents or claims in 3 years
Required
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| Mechanic #2 Full Name as Appears on License or Type "NA"
Required
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| Mechanic #2 Date of Birth as Appears on License or Type "NA"
Required
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| Mechanic #2 License Number and State or type "NA"
Required
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| Mechanic #2 Any violations, accidents or claims in 3 years or select "NA"
Required
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| Mechanic #3 Full Name as Appears on License or Type "NA"
Required
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| Mechanic #3 Date of Birth as Appears on License or Type "NA"
Required
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| Mechanic #3 License Number and State or type "NA"
Required
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| Mechanic #3 Any violations, accidents or claims in 3 years or select "NA"
Required
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| Mechanic #4 Full Name as Appears on License or Type "NA"
Required
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| Mechanic #4 Date of Birth as Appears on License or Type "NA"
Required
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| Mechanic #4 License Number and State or type "NA"
Required
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| Mechanic #4 Any violations, accidents or claims in 3 years or select "NA"
Required
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| Do you employ additional mechanics? If so, please send a list to dward@dwardins.com
Required
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| Do you sell vehicles or equipment?
Required
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| Do you allow customers to sell vehicles or equipment?
Required
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| Do you currently have a Garage Liability Policy?
Required
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| Name of current Insurance Company or type None
Required
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| Has there been a lapse in coverage in the last 3 years?
Required
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| Has the Repair Shop had any claims in the past 36 months
Required
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| What Liability Limit of Insurance do you want quoted?
Required
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| How did you hear about us? Please let us know
Required
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| If you selected "Other," tell us how you heard about us.
Required
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| Is there anything else that you would like for us to know concerning your quote request?
Optional
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| 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
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| 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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