| DEALERSHIP WITHOUT A PHYSICAL LOT |
| (If this is not you, go back and select "Dealer With a Lot") |
| 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 Dealership
Required
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| City
Required
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| State
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| ZIP / Postal Code
Required
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| What Type of Coverage Would You Like Quoted? Select All that Apply
Optional
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| Do you sell, rebuild, or repair autos with a salvage title?
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 Sales Persons or type "None"
Required
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| Number of Full-Time Driver(s) or type "None"
Required
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| Number of Part-Time Driver(s) or type "None"
Required
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| Number of Mechanic(s) or type "None"
Required
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| Number of Vehicle Washers/Detailers or type "None"
Required
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| Number of Non Employees 1099 or type "None"
Required
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| Number of Dealer Plates
Required
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| Driver 1 Legal Name as appears on License
Required
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| Date of Birth for Driver #1
Required
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| Driver 1 License Number
Required
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| Driver 1 Any violations, accidents or claims in 3 years
Required
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| Driver 2 Legal Name as appears on License or type "NA"
Required
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| Driver 2 Date of Birth or type "NA"
Required
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| Driver 2 License Number or type "NA"
Required
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| Driver 2 Any violations, accidents or claims in 3 years or select "NA"
Required
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| Driver 3 Name as appears on License or type "NA"
Required
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| Driver 3 Date of Birth or type "NA"
Required
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| Driver 3 License Number or type "NA"
Required
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| Driver 3 Any violations, accidents or claims in 3 years or select "NA"
Required
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| Driver 4 Name as appears on License or type "NA"
Required
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| Driver 4 Date of Birth or type "NA"
Required
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| Driver 4 License Number or type "NA"
Required
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| Driver 4 Any violations, accidents or claims in 3 years or select "NA"
Required
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| Do you employ additional drivers? If so, please send a list to dward@dwardins.com
Required
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| Anyone allowed to drive a Dealership vehicle home or after hours?
Required
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| If someone drivers a Dealership vehicle home or after hours, list name or names. If no one drives a Dealership vehicle home or after hours, type "None"
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 Dealership 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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| Does Dealership offer Buy Here Pay Here?
Required
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| Will you use your own money (Dealership money) to finance for customers?
Required
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| Does the Dealership Lease or Rent Vehicles?
Required
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| For the Owner - is there a personal insurance policy?
Required
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| If the owner has personal insurance, list the carrier's name. If the owner does not have personal insurance, type "NONE"
Required
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| Do you need a Bond with your Liability insurance?
Required
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| If you need a Bond with your Liability policy, we need your home address including City, State & Zip. If you don't need a bond, type "NA"
Required
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| PLEASE LET US KNOW |
| 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. |
| ENTER VALIDATION CODE |
| For Security of your personal information, enter code and press submit |
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