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Business auto declarations.

POLICY NUMBER:

COMMERCIAL AUTO CA DS 03 03 06
COMPANY NAME AREA                 PRODUCER NAME AREA

ITEM ONE

Named Insured:

Mailing Address:

                   Policy Period

From:
To:                At: 12:01 A.M. Standard Time at your mailing address
Previous Policy Number:

Form Of Business:

[] Corporation    [] Limited Liability Company
[] Partnership    [] Other:

In return for the payment of the premium, and subject to all terms of
this policy, we agree with you to provide the insurance as stated in
this policy.

Premium shown is payable at inception:  $

Audit Period (If Applicable):  [] Annually  [] Semi-Annually
                               [] Quarterly [] Monthly

Endorsements Attached To This Policy:

IL 00 17--Common Policy Conditions (IL 01 46 in Washington)
IL 00 21--Broad Form Nuclear Exclusion (Not applicable in New York)

Countersignature Of Authorized Representative

Name:

Title:

Signature:

Date:


Note

Officers' facsimile signatures may be inserted here, on the policy cover or elsewhere at the company's option.

ITEM TWO

ITEM FOUR

Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums

When used as a premium basis:

FOR PUBLIC AUTOS

Gross Receipts means the total amount to which you are entitled for transporting passengers, mail or merchandise during the policy period regardless of whether you or any other carrier originate the transportation. Gross Receipts does not include:

A. Amounts you pay to railroads, steamship lines, airlines and other motor carriers operating under their own ICC or PUC permits.

B. Advertising revenue.

C. Taxes which you collect as a separate item and remit directly to a governmental division.

D. C.O.D. collections for cost of mail or merchandise including collection fees.

Mileage means the total live and dead mileage of all revenue producing units operated during the policy period.

FOR RENTAL OR LEASING CONCERNS

Gross receipts means the total amount to which you are entitled for the leasing or rental of "autos" during the policy period and includes taxes except those taxes which you collect as a separate item and remit directly to a governmental division.

Mileage means the total of all live and dead mileage developed by all the "autos" you leased or rented to others during the policy period.
Schedule Of Coverages And Covered Autos

This policy provides only those coverages where a charge is shown in
the premium column below. Each of these coverages will apply only to
those "autos" shown as covered "autos". "Autos" are shown as covered
"autos" for a particular coverage by the entry of one or more of the
symbols from the Covered Autos Section of the Business Auto Coverage
Form next to the name of the coverage.

                   Covered
Coverages          Autos     Limit                              Premium

Liability                    $                                  $

Personal Injury              Separately Stated In Each          $
Protection (Or               Personal Injury
Equivalent No-               Protection Endorsement Minus
Fault Coverage)
                             $           Deductible.

Added Personal               Separately Stated In Each Added    $
Injury Protection            Personal Injury Protection
(Or Equivalent               Endorsement.
Added No-Fault
Coverage)

Property Protection          Separately Stated In The Property  $
Insurance                    Protection Insurance Endorsement
(Michigan Only)              Minus

                             $           Deductible

                             For Each Accident.

Auto Medical                 $                                  $
Payments

Medical Expense And          Separately Stated In Each Medical  $
Income Loss                  Expense And Income Loss Benefits
Benefits (Virginia           Endorsement.
Only)

Uninsured Motorists          $                                  $

Underinsured                 $                                  $
Motorists (When Not
Included In
Uninsured Motorists
Coverage)

Physical Damage              Actual Cash Value Or Cost Of       $
Comprehensive                Repair, Whichever Is Less, Minus
Coverage
                             $           Deductible For Each
                                         Covered Auto, But No
                                         Deductible Applies
                                         To Loss Caused By
                                         Fire Or Lightning.
                                         See Item Four For
                                         Hired Or Borrowed
                                         Autos.

Physical Damage              Actual Cash Of Repair,             $
Specified                    Whichever Is Less, Minus
Causes Of Loss
Coverage                     $           Deductible For Each
                                         Covered Auto For
                                         Loss Caused By
                                         Mischief Or
                                         Vandalism. See Item
                                         Four For Hired Or
                                         Borrowed Autos.

Physical Damage              Actual Cash Value Or Cost Of       $
Collision                    Repair, Whichever Is Less, Minus
Coverage
                             $           Deductible For Each
                                         Covered Auto. See
                                         Item Four For Hired
                                         Or Borrowed "Autos".

Physical Damage              $           For Each Disablement   $
Towing And Labor                         Of A Private
                                         Passenger Auto.

                                                                $

                             Premium For Endorsements           $
                             Estimated Total Premium *          $

* This Policy May Be Subject To Final Audit.

ITEM THREE

Schedule Of Covered Autos You Own

Covered Auto Number:

Town And State Where The Covered
Auto Will Be Principally Garaged

Description (Year, Model, Trade Name,
Body Type, Serial Number (S), Vehicle
Identification Number (VIN))

Purchased: Original Cost New                  $
           Actual Cost New (N) Or Used (U)    $

              Classification

               Business
                 Use          Size GVW,
Radius        s=service        GCW Or
of            r=retail     Vehicle Seating    Age
Operation   c=commercial      Capacity       Group

   Primary
    Rating
    Factor          Secondary
                     Rating
Liab.   Phy. Dam.    Factor     Code

Except For Towing, All Physical Damage Loss Is Payable To
You And The Loss Payee Named To The Right As Interests
May Appear At the Time Of The Loss.

Coverages--Premiums, Limits And Deductibles

(Absence of a deductible or limit entry in any column below means that
the limit or deductible entry in the corresponding Item Two column
applies instead.)

Coverages              Limit                                   Premium

Liability              $                                       $

Personal Injury        Stated In Each Personal Injury          $
Protection             Protection Endorsement Minus

                       $                Deductible Shown

Added Personal         Stated In Each Added Personal Injury    $
Injury Protection      Protection Endorsement

Property Protection    Stated In The Property Protection       $
Insurance              Insurance Endorsement Minus
(Michigan Only)
                       $                Deductible Shown

Auto Medical           $                                       $
Payments

Medical Expense And    Stated In Each Medical Expense And      $
Income Loss Benefits   Income Loss Benefits Endorsement For
(Virginia Only)        Each Person

Comprehensive          Stated In Item Two Minus                $

                       $                Deductible Shown

Specified Causes       Stated In Item Two Minus                $
Of Loss
                       $                Deductible Shown

Collision              Stated In Item Two Minus                $

                       $                Deductible Shown

Towing And Labor       $                Per Disablement        $

Covered Auto Number:

Town And State Where The Covered
Auto Will Be Principally Garaged

Description (Year, Model, Trade Name,
Body Type, Serial Number (S), Vehicle
Identification Number (VIN))

Purchased:    Original Cost New                    $
              Actual Cost New (N) Or Used (U)      $

              Classification

               Business
                 Use          Size GVW,
Radius        s=service        GCW Or
of            r=retail     Vehicle Seating    Age
Operation   c=commercial      Capacity       Group

   Primary
    Rating
    Factor          Secondary
                     Rating
Liab.   Phy. Dam.    Factor     Code

Except For Towing, All Physical Damage Loss Is Payable To
You And The Loss Payee Named To The Right As Interests
May Appear At the Time Of The Loss.

Coverages--Premiums, Limits And Deductibles

(Absence of a deductible or limit entry in any column below means
that the limit or deductible entry in the corresponding Item Two
column applies instead.)

Coverages              Limit                                   Premium

Liability              $                                       $

Personal Injury        Stated In Each Personal Injury          $
Protection             Protection Endorsement Minus

                       $                Deductible Shown

Added Personal         Stated In Each Added Personal Injury    $
Injury Protection      Protection Endorsement

Property Protection    Stated In The Property Protection       $
Insurance              Insurance Endorsement Minus
(Michigan Only)
                       $                Deductible Shown

Auto Medical           $                                       $
Payments

Medical Expense And    Stated In Each Me$
Income Loss Benefits   Benefits Endorsement For Each Person
(Virginia Only)

Comprehensive          Stated In Item Two Minus                $

                       $                Deductible Shown

Specified Causes       Stated In Item Two Minus                $
Of Loss
                       $                Deductible Shown

Collision              Stated In Item Two Minus                $

                       $                Deductible Shown

Towing And Labor       $                Per Disablement        $

Covered Auto Number:

Town And State Where The Covered
Auto Will Be Principally Garaged

Description (Year, Model, Trade Name,
Body Type, Serial Number (S), Vehicle
Identification Number (VIN))

Purchased:  Original Cost New                 $
            Actual Cost New (N) Or Used (U)   $

              Classification

               Business
                 Use          Size GVW,
Radius        s=service        GCW Or
of            r=retail     Vehicle Seating    Age
Operation   c=commercial      Capacity       Group

   Primary
    Rating
    Factor          Secondary
                     Rating
Liab.   Phy. Dam.    Factor     Code

Except For Towing, All Physical Damage Loss Is Payable To
You And The Loss Payee Named To The Right As Interests
May Appear At the Time Of The Loss.

Coverages--Premiums, Limits And Deductibles

(Absence of a deductible or limit entry in any column below means
that the limit or deductible entry in the corresponding Item Two
column applies instead.)

Coverages              Limit                                   Premium

Liability              $                                       $

Personal Injury        Stated In Each Personal Injury          $
Protection             Protection Endorsement Minus

                       $                Deductible Shown

Added Personal         Stated In Each Added Personal Injury    $
Injury Protection      Protection Endorsement

Property Protection    Stated In The Property Protection       $
Insurance              Insurance Endorsement Minus
(Michigan Only)
                       $                Deductible Shown

Auto Medical           $                                       $
Payments

Medical Expense And    Stated In Each Medical Expense And      $
Income Loss Benefits   Income Loss Benefits Endorsement For
(Virginia Only)        Each Person

Comprehensive          Stated In Item Two Minus                $

                       $                Deductible Shown

Specified Causes       Stated In Item Two Minus                $

Of Loss                $                Deductible Shown

Collision              Stated In Item Two Minus                $

                       $                Deductible Shown

Towing And Labor       $                Per Disablement        $

Total Premiums

Liability                                                   $
Personal Injury Protection                                  $
Added Personal Injury Protection                            $
Property Protection Insurance (Michigan Only)               $
Auto Medical Payments                                       $
Medical Expense And Income Loss Benefits (Virginia Only)    $
Comprehensive                                               $
Specified Causes Of Loss                                    $
Collision                                                   $
Towing And Labor                                            $

ITEM FOUR

Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums

                                                Factor
         Estimated Cost    Rate Per Each    (If Liability
           Of Hire For       $100 Cost       Coverage Is
State      Each State         Of Hire          Primary)      Premium

         $                 $                                 $

Liability Coverage--Rating Basis, Number Of Days--(For
Mobile Or Farm Equipment--Rental Period Basis)

            Estimated
            Number of
              Days
            Equipment
             Will Be
State        Rented         Base Premium        Factor       Premium

         $                                                   $

                                            Total Premium    $

Cost of hire means the total amount you incur for the hire of "autos"
you don't own (not including "autos" you borrow or rent from your
partners or "employees" or their family members). Cost of hire does
not include charges for services performed by motor carriers of
property or passengers.

Physical Damage Coverage

Coverages        Limit Of Insurance

Comprehensive    Actual Cash Value Or Cost Of Repair, Whichever
                 Is Less, Minus

                 $                Deductible

                 For Each Covered Auto, But No Deductible Applies
                 To Loss Caused By Fire Or Lightning.

                 Estimated Annual   Rate Per Each $100
                   Cost Of Hire     Annual Cost Of Hire   Premium

                 $                  $                     $

Specified        Actual Cash Value Or Cost Of Repair, Whichever Is
Causes Of Loss   Less, Minus

                 $                Deductible

                 For Each Covered Auto For Loss Caused By Mischief
                 Or Vandalism.

                 Estimated Annual     Rate Per Each $100
                   Cost Of Hire      Annual Cost Of Hire   Premium

                 $                   $                     $

Collision        Actual Cash Value Or Cost Of Repair, Whichever Is
                 Less, Minus

                 $                Deductible

                 For Each Covered Auto.

                 Estimated Annual    Rate Per Each $100
                   Cost Of Hire     Annual Cost Of Hire   Premium

                 $                  $                     $

Total Premium:                                            $

ITEM FIVE

Schedule For Non-Ownership Liability

Named Insured's       Rating Basis              Number    Premium
Business

Other Than Garage     Number Of Employees                 $
Service Operations
And Other Than        Number Of Partners                  $
Social Service
Agencies

Garage Service        Number Of Employees                 $
Operations            Whose Principal Duty
                      Involves The Operation
                      Of Autos

Social Service        Number Of Employees                 $
Agencies              Number Of Volunteers                $

                      Total Premiums                      $

ITEM SIX

Schedule For Gross Receipts Or Mileage Basis--Liability
Coverage--Public Auto Or Leasing Rental Concerns

Location No:

(CheckOne)     [ ] Gross Receipts (Per $100)  [ ] Mileage(Per Mile)

Estimated Yearly:

                                                Rates

Liability                                       $
Auto Medical Payments                           $
Medical Expense Benefits (VA Only)              $
Income Loss Benefits (VA Only)                  $

                                                Premiums

Liability                                       $
Auto Medical Payments                           $
Medical Expense Benefits (VA Only)              $
Income Loss Benefits (VA Only)                  $

Location No:

(CheckOne)    [ ] Gross Receipts (Per$100)   [ ] Mileage(Per Mile)

Estimated Yearly:

                                                Rates

Liability                                       $
Auto Medical Payments                           $
Medical Expense Benefits (VA Only)              $
Income Loss Benefits (VA Only)                  $

                                                Premiums

Liability                                       $
Auto Medical Payments                           $
Medical Expense Benefits (VA Only)              $
Income Loss Benefits (VA Only)                  $

Location No:

(Check One)   [ ] Gross Receipts (Per $100)    [ ] Mileage (Per Mile)

Estimated Yearly:

                                           Rates

Liability                                  $
Auto Medical Payments                      $
Medical Expense Benefits (VA Only)         $
Income Loss Benefits (VA Only)             $

                                           Premiums

Liability                                  $
Auto Medical Payments                      $
Medical Expense Benefits (VA Only)         $
Income Loss Benefits (VA Only)             $

                                           Total Premiums

Minimum Liability                          $
Minimum Auto Medical Payments              $
Minimum Medical Expense Benefits (VA Only) $
Minimum Income Loss Benefits (VA Only)     $
Liability                                  $
Auto Medical Payments                      $
Medical Expense Benefits (VA Only)         $
Income Loss Benefits (VA Only)             $

Location Number                            Address
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Article Details
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Title Annotation:APPENDIX D--SPECIMEN FORMS
Publication:Business Auto Coverage Guide, 2nd ed.
Date:Jan 1, 2004
Words:1838
Previous Article:Business auto coverage form.
Next Article:Lessor--additional insured and loss payee.

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