Acord 137 Commercial Auto - Agriculture Insurance

1 TMDATE (MM/DD/YYYY)PRODUCERAPPLICANT (First Named Insured)COVERAGESCOVERED auto SYMBOLSLIMITSCOVERAGESCOVERED auto SYMBOLSLIMITSPHYSICAL DAMAGECOVEREDAUTOSYMBOLSCOVERAGESCOVERED auto SYMBOLSLIMITSPHYSICAL DAMAGECOVEREDCOVERAGESLIMITSDEDUCTIBLEAU TO SYMBOLSTRAILER INTERCHANGECOVERAGESSYMBOL # TRAILERS STATE # DAYSRADIUSDEDUCTIBLECOVERED auto SYMBOLSBI149 CSL$EA PERLIABILITY27BI EACH ACCIDENT$38 PROPERTY DAMAGE$3 TOWING$& LABOR7248 COMPREHENSIVE37248248 MEDICALSPECIFIEDEACH PERSON$PAYMENTSCAUSES OF LOSS3737BI26 CSL$248 COLLISIONEA PERWAIVER OFUNINSURED37BI EACH ACCIDENT$37 DEDUCTIBLEMOTORIST4 PROPERTY DAMAGE$YESSTATESSTATES# DAYS# VEHCOVERAGE/DEDUCTIBLECOST OF HIREIF ANY BASISHIRED/BORROWEDNOLIABILITY$COMP$YESS TATESSPECHIREDGROUP TYPENUMBER OF$C OF LPHYSICALNOEMPLOYEESCOLL$DAMAGENON-OWNED LIABILITYVOLUNTEERSPARTNERSCOVERAGE IS:PRIMARYSECONDARY(1) ANY auto (4) OWNED AUTOS OTHER THAN PRIVATE PASSENGER(7) AUTOS SPECIFIED ON SCHEDULE(2) ALL OWNED AUTOS(5) ALL OWNED AUTOS WHICH REQUIRE NO-FAULT COVERAGE(8) HIRED AUTOS(3) OWNED PRIVATE PASSENGER AUTOS(6) OWNED AUTOS SUBJECT TO COMPULSORY LAW(9) NON-OWNED AUTOSBI4146 CSL$EA PERLIABILITY4247BI EACH ACCIDENT$4246 COMPREHENSIVE$4350 PROPERTY DAMAGE$43474246 SCLFTLSPSPECIFIED$CAUSES OF LOSS4347 FFTW4246 COLLISION$WAIVER OF4347 DEDUCTIBLE424646 TOWINGMEDICALEACH PERSON$$PAYMENTS& LABOR43BI4246 CSL$EA PERUNINSURED43BI EACH ACCIDENT$MOTORIST45 PROPERTY DAMAGE$48 COMPREHENSIVE4948 SPECIFIEDCAUSES OF LOSS49 YESSTATESCOST OF HIREIF ANY BASIS48 COLLISIONNON-TRUCKERS$NOWAIVER OFHIRED/BORROWED$49 DEDUCTIBLEYESSTATESSTATES# DAYS# VEHCOST OF HIREIF ANY BASISHIRED/BORROWEDNOLIABILITY$YESSTATES HIREDGROUP TYPENUMBER OFPHYSICALNONON-OWNEDEMPLOYEESDAMAGEAUTO VOLUNTEERSLIABILITYPARTNERSCOVERAGE IS.

2 PRIMARYSECONDARYOTHEROTHER(44) OWNED AUTOS SUBJECT TO NO-FAULT(46) SPECIFICALLY DESCRIBED AUTOS(49) YOUR TRAILERS IN THE POSSESSION OF(41) ANY auto (45) OWNED AUTOS SUBJECT TO A(47) HIRED AUTOS ONLYANOTHER TRUCKER UNDER A TRAILER(42) OWNED AUTOS ONLYCOMPULSORY UNINSURED(48) TRAILERS IN YOUR POSSESSION UNDERINTERCHANGE AGREEMENT(43) OWNED Commercial AUTOS ONLYMOTORIST LAWA TRAILER INTERCHANGE AGREEMENT(50) NON-OWNED AUTOS ONLYBUSINESS auto SECTIONTRUCKERS SECTIONPLEASE COMPLETE REVERSE SIDEACORD 137 CA (2001/06) Acord CORPORATION 1996 COVERAGES/LIMITS SECTIONCALIFORNIA Commercial AUTOACORDCOVERAGESCOVERED auto SYMBOLSLIMITSPHYSICAL DAMAGECOVEREDCOVERAGESLIMITSDEDUCTIBLEAU TO SYMBOLSTRAILER INTERCHANGECOVERAGESSYMBOL # TRAILERS STATE # DAYSRADIUSDEDUCTIBLECOVERED auto SYMBOLSDATEAPPLICANT SPRODUCER SSIGNATURESIGNATUREBI6167 CSL$EA PER6268BI EACH ACCIDENT$6267 LIABILITY6371 PROPERTY DAMAGE$COMPREHENSIVE6368$64646267 SCLFTLSPSPECIFIED6368 FFTW$CAUSES OF LOSS646267 COLLISION6368$WAIVER OF64 DEDUCTIBLE626463 TOWINGMEDICALEACH PERSON$$PAYMENTS& LABOR636767BI6266 CSL$EA PERUNINSURED6367BI EACH ACCIDENT$MOTORIST64 PROPERTY DAMAGE$69 COMPREHENSIVE7069 SPECIFIEDCAUSES OF LOSS70 YESSTATESCOST OF HIREIF ANY BASIS69 COLLISIONNON-TRUCKERS$NOWAIVER OFHIRED/BORROWED$70 DEDUCTIBLEYESSTATESSTATES# DAYS# VEHCOST OF HIREIF ANY BASISHIRED/BORROWEDNOLIABILITY$YESSTATES HIREDGROUP TYPENUMBER

3 OFPHYSICALNONON-OWNEDEMPLOYEESDAMAGEAUTO VOLUNTEERSLIABILITYPARTNERSCOVERAGE IS:PRIMARYSECONDARYOTHEROTHER(64) OWNED Commercial AUTOS ONLY(67) SPECIFICALLY DESCRIBED AUTOS(70) YOUR TRAILERS IN THE POSSESSION OF(61) ANY auto (65) OWNED AUTOS SUBJECT TO NO-FAULT(68) HIRED AUTOS ONLYANOTHER TRUCKER UNDER A TRAILER(62) OWNED AUTOS ONLY(66) OWNED AUTOS SUBJECT TO A COMPUL-(69) TRAILERS IN YOUR POSSESSION UNDERINTERCHANGE AGREEMENT(63) OWNED PRIVATE PASS AUTOS ONLYSORY UNINSURED MOTORIST LAWA TRAILER INTERCHANGE AGREEMENT(71) NON-OWNED AUTOS ONLYA CREDIT REPORT OR OTHER INVESTIGATIVE REPORT ABOUT YOU MAY BE REQUESTED IN CONNECTION WITH THIS APPLICATION FOR Insurance ANDSUBSEQUENT RENEWALS. ANY INFORMATION WHICH WE HAVE OR MAY OBTAIN ABOUT YOU OR OTHER INDIVIDUALS LISTED AS POLICYHOLDERS ON YOURPOLICY WILL BE TREATED CONFIDENTIALLY. HOWEVER, THIS INFORMATION, AS WELL AS OTHER PERSONAL OR PRIVILEGED INFORMATION SUBSEQUENTLYCOLLECTED, MAY, UNDER CERTAIN CIRCUMSTANCES, BE DISCLOSED WITHOUT PRIOR AUTHORIZATION TO NON-AFFILIATED THIRD PARTIES.

4 WE MAY ALSOSHARE SUCH INFORMATION WITH AFFILIATED COMPANIES FOR SUCH PURPOSES AS CLAIMS HANDLING, SERVICING, UNDERWRITING AND INSURANCEMARKETING. YOU HAVE THE RIGHT TO SEE PERSONAL INFORMATION COLLECTED ABOUT YOU, AND YOU HAVE THE RIGHT TO CORRECT ANY INFORMATIONWHICH MAY BE WRONG. IF YOU ARE INTERESTED IN OBTAINING A DESCRIPTION OF OUR INFORMATION PRACTICES, AND YOUR RIGHTS REGARDINGINFORMATION WE COLLECT, ASK YOUR AGENT, OR, IF YOU HAVE BEEN ISSUED A POLICY, PLEASE WRITE US AT THE ADDRESS PROVIDED WITH YOUR ADDITION, ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FOR MOTOR VEHICLE Insurance COVERAGE CONTAINING ANY STATEMENT THATTHE APPLICANT RESIDES OR IS DOMICILED IN THIS STATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILED IN A STATE OTHER THAN THISSTATE, IS SUBJECT TO CRIMINAL AND CIVIL INSURER WHICH REFUSES TO PROVIDE COVERAGE TO AN APPLICANT WHO IS A "GOOD DRIVER" MUST PROVIDE THE APPLICANT WITH WRITTEN STATEMENTOF THE REASONS IT DENIED COVERAGE.

5 IN GENERAL, UNDER CALIFORNIA LAW A GOOD DRIVER IS A ACCIDENT RESULTING IN ONLY PROPERTY DAMAGE IN THELAST THREE WHO HAS NOT HAD MORE THAN ONE VIOLATION POINT OR MORE THAN ONE AT-FAULTI UNDERSTAND AND ACKNOWLEDGE THAT UNINSURED MOTORISTS BODILY INJURY COVERAGE (UMBI) HAS BEEN OFFERED TO ME, AND THAT I HAVE THEOPTIONS OF SELECTING EITHER UMBI LIMITS LOWER THAN MY BODILY INJURY LIABILITY LIMITS, OR REJECTING UMBI COVERAGE ENTIRELY. IF I HAVEREJECTED UMBI COVERAGE OR SELECTED UMBI LIMITS LOWER THAN MY BODILY INJURY LIABILITY LIMITS, I HAVE ALSO SIGNED THE CALIFORNIA PERSONALAUTO ADDITION, I HAVE BEEN OFFERED WAIVER OF COLLISION DEDUCTIBLE. IF THIS OPTION IS NOT INDICATED ON THIS APPLICATION, THEN I HAVEREJECTED THIS UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE OR IN ANY STATE SUPPLEMENT WILL APPLY TO ALL FUTUREPOLICY RENEWALS, CONTINUATIONS AND CHANGES UNLESS I NOTIFY YOU OTHERWISE IN CARRIER SECTIONENDORSEMENTSACORD 137 CA (2001/06)