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IAD Application Page 1

Dax Kastrin

Direct: 505-697-1914 Fax: 505-404-6259

[email protected] Date

Independent Auto Dealer Commercial Insurance Application

Legal Name of Company:

Date you need coverage to begin:

Doing Business As:

Mailing Address: City: State: Zip Code: Individual Corporation LLC

Partnership Joint Venture Other (describe)

Years in Business:

Owner’s name: Phone: Federal Tax ID#

Email: Fax:

LOCATION INFORMATION

# Street, City, County, State, Zip Code Use of Location (Either Retail Lot, Storage Lot, Office, Other)

1

2

3

Prior Insurance Carrier information

If you are new in business skip to question #3.

Carrier Policy Number Policy Period

From - To Premium

1. Has the dealership’s insurance coverage ever been cancelled or not renewed? ... Yes No 2. Any losses paid in the last three years Yes No

a. If yes, please list any losses in the last three years:

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3. If you are new in business please briefly describe your experience in business and in the automotive industry:

_____________________________________________________________________________________________ 4. Please indicate your percentage of car sales: Retail _____% Wholesale ______% Other ______%, Explain if

Other:_____________________

5. Liability limit requested: ___$100,000 ___$300,000 ___$500,000 ___$1,000,000 ___$2,000,000 6. How many dealer plates do you have? _______________

a. What is your dealer’s license number: _____________

b. Are dealer tags permanently used on a vehicle for business or personal use? ... Yes No 7. Do you own or lease your location?

If leased please indicate the name and address of your landlord: Name (Company or Individual): __________________________ Address:____________________________________________ City: _____________________ State: _____ Zip:___________

Email: ________________________ Phone:____-____-______ Fax:____-____-_______ 8. Do you have a Personal Auto Policy? Yes No (Please provide a copy)

9. Would you like coverage for any of the following:

a. Physical damage for your Auto Inventory Yes No

b. Customers Vehicles (if you work on vehicles for the public) Yes No c. Dealer’s Errors & Omissions Yes No

d. False Pretenses (Theft of vehicles by trick or device) Yes No e. Your building Yes No

f. Your business property (contents) Yes No g. Business Interruption Yes No

h. Employee theft of your property or money Yes No

i. Theft of your money by someone other than an employee Yes No 10. Do you sell or perform any of the following:

a. Service Contracts Yes No b. Gap insurance Yes No c. Credit Life & Disability Yes No d. Buy here / pay here Yes No e. Cars with salvaged titles Yes No f. Auto Parts Yes No

g. Tow vehicles for yourself Yes No h. Tow for hire Yes No

i. Sell vehicles on consignment Yes No If yes, indicate your percentage of sales: ____% j. Rent, lease, or loan your autos Yes No

k. Service & repair of your autos Yes No 11. Your owned auto inventory:

a. What is the average cost of cars you purchase: ___________ b. Number of autos in your inventory: ______

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IAD Application Page 3

12. If you work on or ever have customer’s vehicles in your possession:

a. What is the average cost of vehicles you would have in your possession: _________ b. What is the quantity you would have in your possession at any one time: _________

Property Coverage

* ONLY COMPLETE THIS SECTION IF YOU WANT COVERAGE *

Indicate Construction Type: Frame, Metal, Masonry with Wood Joists

Value Location 1 Square Ft: Approximate Year built:

Value Location 2 Square Ft: Approximate Year built:

Estimate the

replacement value of

your building _{Value Location 3} _{Square Ft:} _{Approximate Year built:}

Limit Location 1 Limit Location 2

Estimate the value of your business

property _{Limit Location 3}

13. Do you occupy the entire premises at your location Yes No

a. If no, please explain: ___________________________________________________________________ 14. Is Service & Repair performed on your autos? Yes No

15. Are customers allowed to take unaccompanied test drives? Yes No – Explain: _____________________ a. Do you have a regular test drive route: Yes No

16. Where are keys to your cars stored: Lock boxes Safe Office peg board Taken home at night 17. Approximately how much are you budgeting for your insurance program: ________________

18. Type of vehicles sold and percentage of sales:

Private Passenger Autos / Vans / Light Trucks______% Motor Homes/ RVs / Campers ______% Motorcycles ______% Off Road (ATV) ______% Heavy Trucks ______%

Other ______% Explain: _____________________________________

Lot Protection

* ONLY COMPLETE THIS SECTION IF YOU WANT COVERAGE FOR YOUR AUTOS *

Location

Perimeter Enclosure

Gates Locked

at Night Well Lit Alarm

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DEALER EMPLOYEE &DRIVERS LIST

PLEASE INCLUDE ALL DRIVERS INCLUDING SPOUSE(S) AND KIDS OVER 14 AND UNDER 18 EVEN IF THEY DO NOT WORK IN THE BUSINESS

Name (Same as on license) Date Of Birth License # State of License

Duties (Indicate NONE for

family members who are not active

in the dealership) Years of Experience Furnished Auto? Status 1. Yes No Part-Time Full-Time 2. Yes No Part-Time Full-Time 3. Yes No Part-Time Full-Time 4. Yes No Part-Time Full-Time 5. Yes No Part-Time Full-Time 6. Yes No Part-Time Full-Time 7. Yes No Part-Time Full-Time 8. Yes No Part-Time Full-Time 9. Yes No Part-Time Full-Time 10. Yes No Part-Time Full-Time 11. Yes No Part-Time Full-Time 12. Yes No Part-Time Full-Time 13. Yes No Part-Time Full-Time 14. Yes No Part-Time Full-Time 15. Yes No Part-Time Full-Time 16. Yes No Part-Time Full-Time 17. Yes No Part-Time Full-Time

18. Yes No Part-Time_Full-Time

19. Yes No Part-Time

Full-Time

20. Yes No Part-Time

Full-Time

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Dealer Bond Application:

IAD Bond Application

Effective Date: ______________

Applicant’s legal business name: ___________________________

Mailing address: _________________ Physical address: __________________ City: _________________ City: __________________ State:_____ Zip:________ State:_____ Zip:________ Has the business, or any owner/applicant:

a. Ever been convicted of a crime? Yes No

b. Ever had their license suspended, revoked or denied? Yes No c. Ever been party to a surety bond claim? Yes No

If Yes to any of the above please explain: _________________________________________________________

ALL OWNERS MUST BE INCLUDED

Owner #1: Fist Name: __________________ Middle Name: _______________ Last Name ___________________ Residence Address: ______________________________________

City: _________________________ State: ____ Zip:_________

Social Security #: ____-___-_______ Marital Status: ________ Own Real Estate Yes No Number of Years in Business: _______ Ownership Percentage in Business _____%

Net Worth: _______________

Owner #2: Fist Name: __________________ Middle Name: _______________ Last Name ___________________ Residence Address: ______________________________________

City: _________________________ State: ____ Zip:_________

Social Security #: ____-___-_______ Marital Status: ________ Own Real Estate Yes No Number of Years in Business: _______ Ownership Percentage in Business _____%

Net Worth: _______________

CREDIT REPORT CONSENT

The undersigned applicant(s) and/or indemnitor(s) understand and agree that by submitting an application for bonding to any of the writing companies of CNA Surety Corporation, the undersigned authorize the verification of information provided and the obtaining of additional information from any source, including obtaining a credit report on the undersigned and/or any other individuals

associated with the business involved, including spouses, at the time of application, in any review or renewal, at the time of any potential or actual claim, or for any other legitimate purpose determined by the writing company in its reasonable discretion.

_________________ _________________________

Date Signature