Contractor's General Liability

Are you the policyowner? Required	Yes No
If no, what is your relationship to the policyowner? If yes, type "NA" Required
Note: All questions hereafter pertain to the policyowner.
CONTACT INFORMATION
First Name Required
Last Name Required
Business Legal Name Required
Contact Primary Phone Number Required
Contact Email Address Required
Mailing Address Required
City Required
State Required	AL GA NC SC TN
ZIP / Postal Code Required
What type of Insurance do you want us to quote? Optional	LiabilityBusiness Auto BuildingContents Workers CompensationUmbrella
Describe your Contractor Operation Required
Business Type Required	Corporation Sole Proprietor Partnership LLC Other
Number of Owners Required
Business Street Address Required
Primary Phone Number Required
E-Mail Address Required
Number of Years in this Business? Required
Gross Annual Sales Required
Number of Employees Required
Annual Employee Payroll, or type "No Employees" Required
Are Subcontractors Used? Required	Yes No
If Subcontractors are used, do you veritify that they have insurance? Required	Yes No No Subcontractors Used
Annual Cost of Subcontractors, or type "No Subcontractors" Required
Do you have Equipment to insure? Required	Yes No
If YES, Please provide a brief description of equipment with a TOTAL VALUE to be insured. If no equipment, type "No equipment to be insured." Required
Do you current have General Liability Insurance? Required	Yes No
If yes, please provide name of current Insurance carrier. If no insurance, type "NA." Required
Have you had a lapse in coverage during the past 3 years? Required	Yes No
Has your company had any claims in the past 3 years? Required	Yes No
Number of Additional Insureds Needed Required
Any Special Requirements Required	Yes No
If yes, please explain special requirements. If no, type "NA" Required
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
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
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.
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.
In reviewing your policy and claim history, we will let you know if we believe we can better your coverage and save money, or we will let you know your policy is competitively priced.
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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