Dealer without a Lot Renewal #2

DEALERSHIP WITHOUT A PHYSICAL LOT

Full Legal Name of Business including any DBA *

First Name *

Last Name *

What is your Title with the company or tell us what your Relationship is to the company *

Primary Phone Number *

E-Mail Address *

Mailing Address *

City *

State *

ZIP / Postal Code *

Number of Years in Business under Legal Name *

Business Type *

Corporation
Sole Proprietor
Partnership
LLC
Other

If Corporation or LLC, Federal ID# Required or if Sole Proprietor SSN Required *

Street Address of Dealership *

City *

State *

ZIP / Postal Code *

What Type of Coverage Would You Like Quoted? Select All that Apply

Garage Liability
Garagekeepers
Workers Compensation
Umbrella for Higher Limits
Shop Contents
Shop Building
Cyber Liability
Employment Practices Liability Insurance (EPLI)

Do you sell, rebuild, or repair autos with a salvage title? *

I do not work with salvaged vehicles
Yes, I work with salvaged vehicles

How Many Owners/Officers? *

Any Inactive Officer(s) - List full name(s) or type "NA" *

Number of Full-Time Clerical Employees or type "None" *

Number of Part-Time Clerical Employees or type "None" *

Number of Sales Persons or type "None" *

Number of Full-Time Driver(s) or type "None" *

Number of Part-Time Driver(s) or type "None" *

Number of Mechanic(s) or type "None" *

Number of Vehicle Washers/Detailers or type "None" *

Number of Non Employees 1099 or type "None" *

Number of Dealer Plates *

Driver 1 Legal Name as appears on License *

Date of Birth for Driver #1 *

Driver 1 License Number *

Driver 1 Any violations, accidents or claims in 3 years *

No known violation(s) for this driver
Yes, this driver has violation(s)

Driver 2 Legal Name as appears on License or type "NA" *

Driver 2 Date of Birth or type "NA" *

Driver 2 License Number or type "NA" *

Driver 2 Any violations, accidents or claims in 3 years or select "NA" *

NA
No known violation(s) for this driver
Yes, this driver has violation(s)

Driver 3 Name as appears on License or type "NA" *

Driver 3 Date of Birth or type "NA" *

Driver 3 License Number or type "NA" *

Driver 3 Any violations, accidents or claims in 3 years or select "NA" *

NA
No known violation(s) for this driver
Yes, this driver has violation(s)

Driver 4 Name as appears on License or type "NA" *

Driver 4 Date of Birth or type "NA" *

Driver 4 License Number or type "NA" *

Driver 4 Any violations, accidents or claims in 3 years or select "NA" *

NA
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 dward@dwardins.com *

No
Yes

Anyone allowed to drive a Dealership vehicle home or after hours? *

Yes
No

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" *

Do you currently have a Garage Liability Policy? *

Yes, my garage has insurance
No

Name of current Insurance Company or type None *

Has there been a lapse in coverage in the last 3 years? *

No, there has not been a lapse in coverage.
Yes, there has been a lapse in coverage.

Has the Dealership had any claims in the past 36 months *

No Claims during past 36 months
Yes there are claim(s)

What Liability Limit of Insurance do you want quoted? *

Does Dealership offer Buy Here Pay Here? *

Yes
No

Will you use your own money (Dealership money) to finance for customers? *

Yes
No

Does the Dealership Lease or Rent Vehicles? *

Yes
No

For the Owner - is there a personal insurance policy? *

Yes, the owner has a personal insurance policy
No, the owner does not have personal insurance

If the owner has personal insurance, list the carrier's name. If the owner does not have personal insurance, type "NONE" *

Do you need a Bond with your Liability insurance? *

Yes, I need a bond
No, I don't need a bond
I'm not sure

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, please type "NA" *

PLEASE LET US KNOW

How did you hear about us? Please let us know *

Internet Search
Ga Indep Auto Dealer Assoc (GIADA)
Mailing from D. Ward
E-Learning Concepts Dealer Training
A Friend
Other

If you selected "Other," tell us how you heard about us. *

Is there anything else that you would like for us to know concerning your quote request?

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. *

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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Auto
&
Home

Life
& Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Dealer without a Lot Renewal #2

Contact Us Today!
770-974-0670

Resources

Contact Us

Auto & Home

Life & Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Dealer without a Lot Renewal #2

Contact Us Today! 770-974-0670

Resources

Contact Us

Auto
&
Home

Life
& Disability

Contact Us Today!
770-974-0670