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Dealers Without a Physical Retail Lot

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(Required)

E-Mail Address(Required)

Mailing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Number of Years in Business under Legal Name(Required)

Untitled

Business Type(Required)

Dealership Address(Required)

Street Address City State / Province / Region 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"(Required)

Number of Dealer Vehicle Plates(Required)

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

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

State Required Dealership Liability Insurance

Inventory Coverage for Your Vehicle, Theft, Fire etc

Coverage for other peoples vehicles

Your Office Contents

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 [email protected] and be sure to label with your Dealership's name.

Number of Owners/Partners/Officers/Members?(Required)

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

Driver #1 Legal Name as appears on License(Required)

First Last

Does Driver #1 have a Georgia Drivers License(Required)

Date of Birth for Driver #1(Required)

Driver #1 Any violations, accidents or claims in past 36 months(Required)

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

First Last

Does Driver #2 have a Georgia Drivers License

Date of Birth for Driver #2

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

Driver #3 Legal Name as appears on License or type "NA"

First Last

Does Driver #3 have a Georgia Drivers License

Date of Birth for Driver #3

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

Driver #4 Legal Name as appears on License or type "NA"

First Last

Does Driver #4 have a Georgia Drivers License

Date of Birth for Driver #4

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

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

Name of the Dealership's employed Mechanic or type "NONE"(Required)

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

Does the Dealership employee Vehicle Detailer(s)?(Required)

Do you employ additional drivers? If so, please send a list to [email protected](Required)

GENERAL DEAERLER QUESTIONS

Anyone allowed to drive a Dealership vehicle home or after hours?(Required)

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"(Required)

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

Has there been a lapse in coverage during the past 3 years?(Required)

Has the Dealership had any claims or losses during the past 3 years?(Required)

Does the Dealership offer "Buy Here Pay Here"?(Required)

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

Does your Dealership do any type of repossession?(Required)

Does the Dealership Lease, Rent or Loan Vehicles?(Required)

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

Will you sell, rebuild, or repair auto with a salvage title?(Required)

Does your Dealership have a Tow Truck?(Required)

Does the owner have a personal insurance policy?(Required)

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"(Required)

Do you need a Bond with your Liability insurance?(Required)

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"(Required)

How did you hear about us? Please let us know(Required)

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.(Required)

First Last

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.

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.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Dealers Without a Physical Retail Lot

OWNERS AND DRIVERS INFORMATION

GENERAL DEAERLER QUESTIONS

SIGNATURE REQUIRED

ADDITIONAL INFORMATION NEEDED

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