ACORD BUSINESS AUTO SECTION DATE …

1 ACORD BUSINESS auto SECTION . date (MM/DD/YY). TM. PRODUCER PHONE APPLICANT. (A/C, No, Ext): (402)592-0900 (First FAX (402)592-0962 Named Insured). Associated Underwriters, Inc. 11115 "O" Street EFFECTIVE date EXPIRATION date DIRECT BILL PAYMENT PLAN AUDIT. Box 45820 AGENCY BILL. Omaha, NE 68145-0820 FOR. COMPANY. CODE: SUB CODE: USE ONLY. AGENCY. CUSTOMER ID: COVERAGES/LIMITS. COVERAGES COVERED auto SYMBOLS LIMITS COVERAGES COVERED auto SYMBOLS LIMITS. BI. 1 4 9 CSL EA PER $. LIABILITY 2 7 BI EACH ACCIDENT $. 3 8 PROPERTY DAMAGE $. PERSONAL INJURY 5 OR EQUIVALENT DEDUCTIBLE.

2 PROTECTION 7 NO-FAULT COVERAGE $ PHYSICAL DAMAGE. ADDITIONAL 5 TOTAL W/C $ TOWING 3. $. 7 $ M/E $ & LABOR 7. MEDICAL 2 4 8 2 4 8. EACH PERSON $ COMPREHENSIVE. PAYMENTS 3 7 3 7. BI. 2 6 CSL EA PER $ SPECIFIED 2 4 8. UNINSURED CAUSES OF LOSS. 3 7 BI EACH ACCIDENT $ 3 7. MOTORIST. 4 PROPERTY DAMAGE $ 2 4 8. BI COLLISION. 2 6 CSL EA PER $ 3 7. UNDERINSURED. 3 7 BI EACH ACCIDENT $. MOTORIST. 4 PROPERTY DAMAGE $. STATES COST OF HIRE iF ANY BASIS STATES # DAYS # VEH COVERAGE/DEDUCTIBLE. HIRED/BORROWED. LIABILITY $ COMP $. STATES HIRED SPEC. GROUP TYPE NUMBER OF C OF L $.

3 PHYSICAL. NON-OWNED EMPLOYEES DAMAGE COLL $. LIABILITY VOLUNTEERS. PARTNERS COVERAGE IS: PRIMARY SECONDARY. ENDORSEMENTS, FORMS, CONDITIONS. COVERED (1) ANY auto (4) OWNED AUTOS OTHER THAN PRIVATE PASSENGER (7) AUTOS SPECIFIED ON SCHEDULE. auto (2) ALL OWNED AUTOS (5) ALL OWNED AUTOS WHICH REQUIRE NO-FAULT COVERAGE (8) HIRED AUTOS. SYMBOLS (3) OWNED PRIVATE PASSENGER AUTOS (6) OWNED AUTOS SUBJECT TO COMPULSORY LAW (9) NON-OWNED AUTOS. DRIVER INFORMATION. LIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT WILL DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS .

4 DRIVER YEAR DRIVERS LICENSE NUMBER/ STATE USE %. # NAME (Include address, if required) date OF BIRTH LIC SOCIAL SECURITY NUMBER LIC VEH # USE. VEHICLE DESCRIPTION. VEH # YEAR BODY SYM/AGE COST NEW. MAKE: TYPE: MODEL: : $. TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM. CITY, STATE, ZIP. WHERE GARAGED. DRIVE TO WORK/SCHOOL USE CHECK UNDRINS DEDUCTIBLES SPEC. COMM'L COVERAGES ADD'L PIP MOTOR F LSP ACV COMP C OF L. TOWING. UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY & LABOR FT COMP AA ST AMT $. UNINS SPEC. 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL.

5 ACORD 127 (8/94) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1993. VEHICLE DESCRIPTION (continued). VEH # YEAR BODY SYM/AGE COST NEW. MAKE: TYPE: MODEL: : $. TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM. CITY, STATE, ZIP. WHERE GARAGED. DRIVE TO WORK/SCHOOL USE CHECK UNDRINS DEDUCTIBLES SPEC. COMM'L COVERAGES ADD'L PIP MOTOR F LSP ACV COMP C OF L. TOWING. UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY & LABOR FT COMP AA ST AMT $. UNINS SPEC. 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL. VEH # YEAR BODY SYM/AGE COST NEW. MAKE: TYPE: MODEL: : $.

6 TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM. CITY, STATE, ZIP. WHERE GARAGED. DRIVE TO WORK/SCHOOL USE CHECK UNDRINS DEDUCTIBLES SPEC. COMM'L COVERAGES ADD'L PIP MOTOR F LSP ACV COMP C OF L. TOWING. UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY & LABOR FT COMP AA ST AMT $. UNINS SPEC. 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL. VEH # YEAR BODY SYM/AGE COST NEW. MAKE: TYPE: MODEL: : $. TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM. CITY, STATE, ZIP. WHERE GARAGED. DRIVE TO WORK/SCHOOL USE CHECK UNDRINS DEDUCTIBLES SPEC.

7 COMM'L COVERAGES ADD'L PIP MOTOR F LSP ACV COMP C OF L. TOWING. UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY & LABOR FT COMP AA ST AMT $. UNINS SPEC. 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL. VEH # YEAR BODY SYM/AGE COST NEW. MAKE: TYPE: MODEL: : $. TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM. CITY, STATE, ZIP. WHERE GARAGED. DRIVE TO WORK/SCHOOL USE CHECK UNDRINS DEDUCTIBLES SPEC. COMM'L COVERAGES ADD'L PIP MOTOR F LSP ACV COMP C OF L. TOWING. UNDER 15 MILES PLEASURE RETAIL LIAB MED PAY & LABOR FT COMP AA ST AMT $. UNINS SPEC.

8 15 MILES OR OVER FARM SERVICE PIP MOTOR C OF L FTW COLL $ $ COLL. ADDITIONAL INTEREST/CERTIFICATE RECIPIENT (Attach ACORD 45 for additional names). INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER. ADDITIONAL INSURED LOCATION: BUILDING: LOSS PAYEE VEHICLE: BOAT: MORTGAGEE SCHEDULED ITEM NUMBER: LIENHOLDER OTHER. EMPLOYEE AS LESSOR. ITEM DESCRIPTION: GENERAL INFORMATION. EXPLAIN ALL "YES" RESPONSES YES NO 7. DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL? 1. WITH THE EXCEPTION OF ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY 8.

9 ANY HOLD HARMLESS AGREEMENTS? OWNED BY AND REGISTERED TO THE APPLICANT? 9. ANY VEHICLES USED BY FAMILY MEMBERS? 2. DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS ? IF SO, PLEASE IDENTIFY IN REMARKS. 3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION? 10. DOES THE APPLICANT OBTAIN MVR VERIFICATIONS? 4. ARE ANY VEHICLES LEASED TO OTHERS? 11. DOES THE APPLICANT HAVE A SPECIFIC DRIVER RECRUITING METHOD? 5. ARE ANY VEHICLES CUSTOMIZED, ALTERED OR HAVE SPECIAL EQUIPMENT? 12. ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION? 6. ARE ICC, PUC OR OTHER FILINGS REQUIRED?

10 13. ANY VEHICLES OWNED BUT NOT SCHEDULED ON THIS APPLICATION? DESCRIPTION OF GARAGE/STORAGE LOCATIONS MAXIMUM DOLLAR VALUE SUBJECT TO LOSS. REMARKS. UNINSURED AND UNDERINSURED MOTORISTS COVERAGES (Check the appropriate box(es) below and sign where applicable). DO NOT USE IN AR, AZ, CA, CT, DE, FL, GA, IA, IL, MD, NJ, NV, OK, OR, PA, RI, SC, WV; USE SPECIFIC STATE SUPPLEMENT. MINIMUM UM LIMITS REQUIRED IN DC, ME, MN, MO, VT, VA, WA, WI. SELECTING UM AND UIM LIMITS EQUAL TO MY LIABILITY LIMITS, I UNDERSTAND AND ACKNOWLEDGE THAT UNINSURED MOTORISTS. (UM) AND UNDERINSURED MOTORISTS (UIM) COVERAGES HAVE SELECTING UM AND UIM LIMITS LOWER THAN MY LIABILITY LIMITS, OR.