Dealer without a Lot Renewal Form

DEALERSHIP WITHOUT A PHYSICAL LOT

OWNERS AND DRIVERS INFORMATION

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 your Dealer's Office *

City *

State *

ZIP / Postal Code *

Will the Dealership use any other location for storage of vehicles including any residence location? If so, type full address including city and zip code. If none, type "NONE" *

Number of Dealer Vehicle Plates *

Any other plates - other than for Vehicles? If none, type "NONE" or list # and type *

What Type of Coverage would you like quoted? Select all that appy

State Required Dealership Insurance
Dealership's Inventory for collision, wind, et
Coverage for other peoples vehicles
Your Office Contents
Workers Comp for your employees
Your Personal Auto
Your Home Insurance
Umbrella for Personal or Business

What Liability Limit of Insurance do you want quoted? *

OWNERS AND DRIVERS INFORMATION

In this section you will need Drivers License information including any violations for the past 36 months. If more than 4 individuals, please type a list and submit to DWard@dwardins.com and be sure to label with your Dealership's name.

Number of Owners/Partners/Officers/Members? *

Name(s) of ALL Owners/Partners/Officers/Memberss *

Driver 1 Legal Name as appears on License *

Does Driver 1 have a Georgia Drivers License *

Yes
No

Date of Birth for Driver #1 *

Driver 1 License Number *

Driver 1 Any violations, accidents or claims in past 36 months *

Yes, Driver 1 has violations during past 36 months
No known violations for this driver

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

Does Driver 2 have a Georgia Drivers License or select "NA" *

NA
Yes
No

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" *

Does Driver 3 have a Georgia Drivers License or select "NA" *

NA
Yes
No

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" *

Does Driver 4 have a Georgia Drivers License or select "NA" *

NA
Yes
No

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)

Name(s) of any Clerical Employee or type "NONE" *

Name of the Dealership's employed Mechanic or type "NONE" *

Will or does the Dealership hire Contract Drivers from the auctions to drive the Dealership's vehicles back to its lot? *

No
Yes

Does the Dealership employee Vehicle Detailer(s)? *

No
Yes

Do you employ additional drivers? If so, please send a list to dward@dwardins.com *

No
Yes

GENERAL DEAERLER QUESTIONS

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

Yes
No

If someone drives a Dealership vehicle home or drivers after hours, list name or names. If no one drives a Dealership vehicle home or after hours type "NONE" *

Name of the Dealership's current insurance carrier or type "New Start Up" or None *

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

"NA" my Dealership is a start up
No, there has not been a lapse in coverage
Yes, there has been a lapse in coverage

Has the Dealership had any claims or losses during the past 3 years? *

"NA" my Dealership is a start up
No Claims during paste 3 years
Yes there are claim(s)

Does the Dealership offer "Buy Here Pay Here"? *

No
Yes

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

Yes
No

Does your Dealership do any type of repossession? *

No
Yes

Does the Dealership Lease, Rent or Loan Vehicles? *

No
Yes

Does the Dealership use its vehicles for ride share (Uber Eats, etc)? *

No, my Dealership does not provide ride share
Yes, my Dealers provides ride share

Will you sell, rebuild, or repair auto with a salvage title? *

No, I will not work on or sell salvaged vehicles
Yes, I will work on and or sell salvaged vehicles

Does your Dealership have a Tow Truck? *

No
Yes

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(s) has personal car insurance, list the insurance company's name beside the owner(s) name or type "NONE". Example: John Doe with Progressive and Bill Doe with Safeco or John Doe with Progressive and Bill Doe "None" or Neither "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 up and coming Renewal?

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.

I am an Owner/Partner/Officer/Member of the Dealership and by typing my name warrants my signature. *

ADDITIONAL INFORMATION NEEDED

After you have submitted your quote request, we may need to obtain your Claim History or a copy of your Current Policy if applicable.

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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For Security of your personal information, enter code and press submit

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Dealer without a Lot Renewal Form

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770-974-0670

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Auto & Home

Life & Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Dealer without a Lot Renewal Form

Contact Us Today! 770-974-0670

Resources

Contact Us

Auto
&
Home

Life
& Disability

Contact Us Today!
770-974-0670