GARAGE AND DEALERS SECTION DATE (MM/DD/YYYY)

1 EFFECTIVE DATENAMED INSURED(S)POLICY NUMBERNAIC CODECARRIERAGENCY 1991-2014 ACORD CORPORATION. All rights ACORD name and logo are registered marks of ACORDPage 1 of 4 GARAGE AND DEALERS SECTIONAGENCY CUSTOMER ID:DATE (MM/DD/YYYY)NUMBER OF GALLONS OF GAS PUMPED PER YEAR:ANNUAL GROSS SALES $SERVICE OR REPAIR SHOPSCOVERAGES / LIMITSUSE ACORD 138 FOR YOUR STATE TO PROVIDE COVERAGES / LIMITS INFORMATIONNON- DEALERS PREMISES & OPERATIONS# EMPLOYEESESTIMATED ANNUALREMUNERATION#LOC$$$ DEALERS PHYSICAL DAMAGECOVERAGENEWYOUR INTEREST INCOVERED AUTOSYOU OWNYOUR INTEREST ONLYIN FINANCEDCOVERED AUTOSYOURS AND FINANCEDINTERESTS INCOVERED AUTOSUSEDCOMPREHENSIVESPECIFIED PERILSCOLLISION* MARITAL STATUS / CIVIL UNION (if applicable)

2 CITY, STATE AND ZIP CODENAMEUSE%VEH #USEHIREDATELICSTATESOCIAL SECURITY NUMBERDRIVERS LICENSE NUMBER/LICYEAREXPYRSDATE OF BIRTHSTAT* MARSEX#DRIVERLIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT WILL DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY 163 attached for additional driversDRIVER INFORMATIONTHE NUMBER OF WEEKS WORKED ARE TO BE COUNTED AS 1/2 RATING PART-TIME EMPLOYEES WORKING AN AVERAGE OF LESS THAN 20 HOURS A WEEK FORTHE NUMBER OF WEEKS WORKED ARE TO BE COUNTED AS 1 RATING UNIT : 1.

3 PART-TIME EMPLOYEES WORKING AN AVERAGE OF 20 HOURS OR MORE A WEEK FORRELATIVES OF ANY PERSON DESCRIBED IN CLASS : INACTIVE-PROPRIETORS, PARTNERS OR OFFICERS AND THEIR RELATIVES AND THEANY OF THE FOLLOWING PERSONS WHO ARE REGULARLY FURNISHED WITH A COVEREDCLASS II - NON-EMPLOYEESALL OTHERS - ALL OTHER EMPLOYEESFURNISHED A COVERED PRINCIPAL DUTY INVOLVES THE OPERATION OF COVERED AUTOS OR WHO ISOPERATION, SALESPERSONS, GENERAL MANAGERS, SERVICE MANAGERS; ANY EMPLOYEEREGULAR OPERATOR - PROPRIETORS, PARTNERS AND OFFICERS ACTIVE IN THE GARAGECLASS I - EMPLOYEESDEFINITIONS.

4 BY LOCATION NUMBERCLASS OF OPERATORSCLASS IREGULAR OPERATORSEMPLOYEESALL OTHERSCLASS IIUNDER AGE 25 NON-EMPLOYEESALL OTHERSAUTO DEALERS OPERATORSBUSINESS / VEHICLE STORAGE INFORMATION%%%%%%%%%%%%VEHICLE STORAGETYPE OF FACILITYLOCATION #BUILDINGSTANDARD OPEN LOTNON-STANDARD OPEN LOTAUTO SERVICE OPERATIONS ORTRAILER SALESSTORAGE / GARAGE / PUBLIC PARKINGCOMMERCIAL TRAILER DEALERSERVICE STATIONMOBILE HOME TRAILER DEALERREPAIR SHOP%%%%%%SNOWMOBILERECREATIONAL VEHICLEMOTORCYCLETRUCK-TRACTORCARNON-FRA NCHISEDFRANCHISEDAUTO DEALERSACORD 128 (2014/12)Attach to ACORD 125 Page 2 of 4 AGENCY CUSTOMER ID:Y / NEXPLAIN ALL "YES" RESPONSES1.

5 A speeding violation of up to six (6) mph that occurs in an area with a maximum posted speed limit from 30 mph through 54 mph, or2. A speeding violation of up to ten (10) mph that occurs in an area with a maximum posted speed limit from 55 mph through 75 ONLY IN KANSAS: UNDER KANSAS LAW, THE FOLLOWING TRAFFIC VIOLATIONS ARE NOT REQUIRED TO BE REPORTED TO DRIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS?GENERAL APPLICANT RENT, LEASE OR LOAN VEHICLES TO OTHERS? APPLICANT PICK-UP OR DELIVER CUSTOMER'S CARS?

6 PICK-UP OR DELIVERY EXCEED 50 MILES? TIRE RECAPPING OR RETREADING PERFORMED? APPLICANT OWN OR SPONSOR A CAR FOR RACING? APPLICANT HANDLE BUTANE, PROPANE OR OTHER GASES? VEHICLES FURNISHED FOR GROUP OR ORGANIZATIONS? APPLICANT PERFORM SPRAY PAINTING OR WELDING? APPLICANT DISMANTLE AUTOS OR HAVE SALVAGE OPERATION? APPLICANT USE TOW TRUCKS? EMPLOYEES REGULARLY USE OWN AUTOS ON COMPANY BUSINESS? APPLICANT DRIVE-AWAY OR HAUL-AWAY VEHICLES FROM FACTORY DISTRIBUTING POINT OR OTHER DEALERS ? APPLICANT PARK CUSTOMER'S VEHICLES ON PUBLIC STREETS OR OFF PREMISES?

7 A CHARGE MADE FOR PARKING? (Give locations, # attendants) PRIVATE PROTECTION SYSTEMS? (fences, dogs, alarms, guards) APPLICANT INVOLVED IN ANY "NON GARAGE " OPERATIONS? (Mini Marts, Liquor Stores, etc) APPLICANT PERFORM ROAD EMERGENCY SERVICES?ACORD 128 (2014/12)Page 3 of 4 ADDITIONAL INTEREST / CERTIFICATE RECIPIENTACORD 45 attached for additional namesINTERESTRANK:NAME AND ADDRESSREFERENCE #:CERTIFICATE REQUIREDINTEREST IN ITEM NUMBERADDITIONAL INSUREDLOSS PAYEELIENHOLDEREMPLOYEE AS LESSORVEHICLE:SCHEDULED ITEM NUMBER:OTHERITEM DESCRIPTION:INTERESTRANK:NAME AND ADDRESSREFERENCE #:CERTIFICATE REQUIREDINTEREST IN ITEM NUMBERADDITIONAL INSUREDLOSS PAYEELIENHOLDEREMPLOYEE AS LESSORVEHICLE:SCHEDULED ITEM NUMBER:OTHERITEM DESCRIPTION:INTERESTRANK.

8 NAME AND ADDRESSREFERENCE #:CERTIFICATE REQUIREDINTEREST IN ITEM NUMBERADDITIONAL INSUREDLOSS PAYEELIENHOLDEREMPLOYEE AS LESSORVEHICLE:SCHEDULED ITEM NUMBER:OTHERITEM DESCRIPTION:INTERESTRANK:NAME AND ADDRESSREFERENCE #:CERTIFICATE REQUIREDINTEREST IN ITEM NUMBERADDITIONAL INSUREDLOSS PAYEELIENHOLDEREMPLOYEE AS LESSORVEHICLE:SCHEDULED ITEM NUMBER:OTHERITEM DESCRIPTION:REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)AGENCY CUSTOMER ID:ACORD 128 (2014/12)ACORD 128 (2014/12)THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THEANSWERS TO QUESTIONS ON THIS APPLICATION.

9 HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF 4 of 4 NATIONAL PRODUCER NUMBER(Required in Florida)PRODUCER'S SIGNATUREDATEAPPLICANT'S SIGNATUREPRODUCER'S NAME (Please Print)STATE PRODUCER LICENSE NOSIGNATUREAGENCY CUSTOMER ID:Applicable in NJAny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil in PRAny person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes thepresentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur afelony and, upon conviction.

10 Shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousanddollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thusestablished may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) in ORAny person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as toany material fact may be violating state in ME, TN, VA and WAIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.