Dealership Information
Thank you for choosing Dealer Insurance Services LLC to met your insurance needs. Please provide as many details as possible so we can provide you with an accurate quote.
Dealership Name
*
Dealership Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dealership Phone Number
*
Please enter a valid phone number.
Business Email
example@example.com
Website
Owner Name
*
First Name
Last Name
Owner's date of birth and driver's license.
Contact name - if different from owner
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Years in business
Back
Next
Dealership Type and Opperations
Please include as many details as possible.
Type of Dealership
*
Used Car Dealer
New and Used Car Dealer
Repair Shop with Dealership
Wholesale Dealer
Number of vehicles sold annually
Average number of vehicles on the lot
Average wholesale price per vehicle
Location Details
Do you own or lease the location?
*
Please Select
Own
Lease
Building square footage:
Business Hours
Number of employees
*
Employee Details: Name, date of birth, and driver's license number.
Back
Next
Insurance History
Do you currently have insurance?
*
Please Select
Yes
No
If yes, please answer the following questions.
If yes, current insurance company:
Policy expiration date:
Have you had any claims in the past three years?
Please Select
Yes
No
If yes, please provide the details of the claim:
Please provide a copy of your loss history for the last 3 years.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Coverage Requirements
Desired start date
*
-
Month
-
Day
Year
Date
What types of coverage are you interested in? (Check all that apply)
*
Garage Liability (Required for the state of Missouri)
Garagekeepers Liability (For repair shops)
Dealers Open Lot
Business Property
General Liability
Workmans Compensation
Other
Additional Details
Are there any other services you offer? (Ex. Repair, body work)
Do you transport vehicles between locations?
Please Select
Yes
No
If yes, how many trips per month and maximum radius.
Additional comments or requests.
Disclaimer
By submitting this form, you authorize Dealer Insurance Services LLC to use the provided information to generate an insurance quote. Your information will be kept confidential.
Submit
Should be Empty: