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Auto
Home
Business
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Home
Commercial Auto Form
Commercial Auto Form
Full Legal Name of Business including any DBA
(Required)
Full Name
(Required)
First
Last
What is your TITLE with the company or tell us what your Relationship is to the company? *
(Required)
Primary Phone Number
Email
(Required)
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Number of Years in Business under Legal Name
(Required)
Business Type
(Required)
Corporation
Sole Proprietor
Partnership
LLC
Describe how the Business Auto(s) will be Used
(Required)
Will Vehicle be Garaged at the Mailing Address?
(Required)
Yes
No
If No, Where will Vehicle be Stored?
Do you operate an office at a location different from the mailing address?
(Required)
Yes
No
If Yes, Location of Office (Street Address)
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Do you share your lot premises with another business?
(Required)
Yes
No
If yes, what business do you share your lot premises with? If no, type "NA."
(Required)
How Many Owners/Officers?
(Required)
Driver 1 Must Be Owner
Full Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Driver #1 Any violations, accidents or claims in 3 years
(Required)
No known violation(s) for this driver
Yes, this driver has violation(s)
Driver #2 Owner
Owner
Non-Owner
Driver #2 Legal Name as appears on License
Driver #2 Date of Birth
Driver #2 Any violations, accidents or claims in 3 years
N/A
No known violation(s) for this driver
Yes, this driver has violation(s)
Driver #3 Owner
Owner
Non-Owner
Driver #3 Legal Name as appears on License
Driver #3 Date of Birth
Driver #3 Any violations, accidents or claims in 3 years
N/A
No known violation(s) for this driver
Yes, this driver has violation(s)
Driver #4 Owner
Owner
Non-Owner
Driver #4 Legal Name as appears on License
Driver #4 Date of Birth
Driver #4 Any violations, accidents or claims in 3 years
N/A
No known violation(s) for this driver
Yes, this driver has violation(s)
Do you employ additional drivers? If so, please send a list to
[email protected]
(Required)
Yes
No
Anyone allowed to drive a vehicle home or after hours?
(Required)
Yes
No
If someone drives a vehicle home or after hours, list name or names. If no one drives a vehicle home or after hours, type "None"
(Required)
Do you currently have a Business Auto Liability Policy?
(Required)
Yes
No
I had a policy but it lapsed
Name of current Insurance Company or type None
(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.
Has there been any claims in the past 36 months?
(Required)
No Claims during past 36 months
Yes there are claim(s)
What Liability Limit of Insurance do you want quoted?
(Required)
State Minimum
$300,000
$500,000
$1,000,000
Quote Umbrella
For the Owner - Do you have a personal insurance policy?
(Required)
Yes, the owner has a personal insurance policy
No, the owner does not have personal insuranc
If the owner has personal insurance, list the carrier's name. If the owner does not have personal insurance, type "NONE"
(Required)
PLEASE LET US KNOW
(Required)
Internet Search
Ga Indep Auto Dealer Assoc (GIADA)
Mailing from D. Ward
E-Learning Concepts Dealer Training
A Friend
Other
Is there anything else that you would like for us to know concerning your up and coming Renewal?
SIGNATURE REQUIRED (By typing my name warrants my 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.
Disclosure Statement
By submitting this form, I agree to receive conversational text messages from D. Ward Insurance Services using the contact information provided. For help, reply HELP. Opt-out of receiving text messages at any time by sending STOP. Message and data rates may apply. Message frequency varies.
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