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1 Elemental Risk Management is a commercial insurance agency locally owned and operated in Albuquerque, NM. At ERM, we focus our attention on the unique needs and liability exposures of Independent Auto Dealerships. In an era of one size fits all insurance programs, ERM stands out by taking an individualized approach to our clients insurance programs. ERM analyzes our clients unique businesses, growth goals, and risk tolerances to create customized solutions and tools to help protect each client s assets and create financial growth. The result consistent value and impeccable service to our clients and carriers which exceed their expectations. Enclosed you will find Insurance and Bond Applications. If you are interested in partnering with ERM, please complete the application as best as you can and or fax it to us. If you are new in business, our typical turn around time to procure an insurance program is two weeks or less. Please feel free to contact us with questions. Thank you for considering ERM to manage your dealership s insurance program. Sincerely, Dax Kastrin Owner Agent dax@erm ins.com P f in.com

2 Dax Kastrin Direct: Fax: Date Legal Name of Company: Independent Auto Dealer Commercial Insurance Application 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# Fax: LOCATION INFORMATION # Street, City, County, State, Zip Code 1 Use of Location (Either Retail Lot, Storage Lot, Office, Other) 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? Any losses paid in the last three years a. If yes, please list any losses in the last three years: Date of Loss Description or Type of Claim Amount Paid IAD Application Page 1

3 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, 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? 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: Phone: - - Fax: Do you have a Personal Auto Policy? (Please provide a copy) 9. Would you like coverage for any of the following: a. Physical damage for your Auto Inventory b. Customers Vehicles (if you work on vehicles for the public) c. Dealer s Errors & Omissions d. False Pretenses (Theft of vehicles by trick or device) e. Your building f. Your business property (contents) g. Business Interruption h. Employee theft of your property or money i. Theft of your money by someone other than an employee 10. Do you sell or perform any of the following: a. Service Contracts b. Gap insurance c. Credit Life & Disability d. Buy here / pay here e. Cars with salvaged titles f. Auto Parts g. Tow vehicles for yourself h. Tow for hire i. Sell vehicles on consignment If yes, indicate your percentage of sales: % j. Rent, lease, or loan your autos k. Service & repair of your autos 11. Your owned auto inventory: a. What is the average cost of cars you purchase: b. Number of autos in your inventory: c. Which floor plan companies do you use or plan on using: AFC DSC MAFS Other: IAD Application Page 2

4 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: Estimate the replacement value of your building Estimate the value of your business property 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: Value Location 3 Square Ft: Approximate Year built: Limit Location 1 Limit Location 2 Limit Location Do you occupy the entire premises at your location a. If no, please explain: 14. Is Service & Repair performed on your autos? 15. Are customers allowed to take unaccompanied test drives? Explain: a. Do you have a regular test drive route: 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 Loc. #1 Loc. #2 Loc. #3 Loc. #4 Loc. #5 Perimeter Enclosure Gates Locked at Night Well Lit Alarm Average # of Cars IAD Application Page 3

5 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 Furnished Auto mean the indicates person has 24/7 access to one of your vehicles IAD Driver Schedule Page 1

6 Dealer Bond Application: Effective Date: Applicant s legal business name: Mailing address: City: State: Zip: Physical address: City: State: Zip: Has the business, or any owner/applicant: a. Ever been convicted of a crime? b. Ever had their license suspended, revoked or denied? c. Ever been party to a surety bond claim? If 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 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 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 Print IAD Bond Application