Business Insurance

BUSINESS INSURANCE QUOTE FORM
The Quote Form is our preliminary process of obtaining the necessary underwriting information. Be as thorough as possible. The current policy and claim history will also be required as part of the underwriting process.
First Name Required
Last Name Required
Contact Primary Phone Number Required
E-Mail Address Required
Business Legal Name Required
Doing Business As Name or Type "NA" Required
Number of Years in this Business? Required
What type of Insurance do you want us to quote? Optional	LiabilityBusiness Auto EquipmentBuilding ContentsUmbrella Workers Compensation
Mailing Address Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
Business Type Required	Corporation Sole Proprietor Partnership LLC Other
Number of Owners or Officers Required
Describe your Business Opeartion Required
Business Location (Indicate "same" if it is same as mailing address) Required
Current Estimated Gross Annual Sales or Receipts Required
Number of Employees (excluding Owners and Officers) Required
Annual Employee Payroll (Excluding Owners or Officers) Required
Are Subcontractors Used? Required	Yes No
If Subcontractors are used, do you veritify that they have insurance? Required	Yes No No Subcontractors Used
Number of Non Employees 1099s Required
Annual Cost of Non Employees 1099s or type "NA" Required
Annual Cost of Subcontractors or Type "NA" Required
BUILDING & CONTENTS INFORMATION
Do you own the Building? Required	Yes No
How much Contents Coverage should we quote? Required
Construction Type Required	Frame Masonry Masonry Non-Combustible All Metal Other
Total Building Square Footage? Required
Your Occupied Square Footage Required
Year the Building was Built (est) Required
Age of the Roof Required
Is there a sprinkler system in building? Required	Yes No
CURRENT INSURANCE INFORMATION
Do you currently have Business Insurance? Required	Yes, I currently have Business Insurance No
If yes, please provide name of current Insurance carrier. If no insurance, type "NA." 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.
Number of Additional Insureds Needed, if applicable or type "NA" Required
Has your business had any claims in the past 3 years? Required	Yes No
Is there anything else that you would like for us to know concerning your quote request? Optional
How did you hear about us? Please let us know Required
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
Please note - if the Business is insured, a copy of the policy and claim history will be required. They can be obtained from your current agent by requesting the documents to be sent electronically to you.
Thank you for time and we will be in touch with you today unless this is after hours or on the weekend - Debbie Ward and Valerie Moore
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

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