AGENCY CUSTOMER ID: NORTH CAROLINA …

1 AGENCY CUSTOMER ID: NORTH CAROLINA COMMERCIAL AUTO DATE (MM/DD/YYYY). COVERAGES / LIMITS SECTION. AGENCY NAMED INSURED(S). POLICY NUMBER EFFECTIVE DATE CARRIER NAIC CODE. BUSINESS AUTO SECTION. 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 $. PHYSICAL DAMAGE. * Include the Fire District name and code # if fire or COMP / OTC coverage is provided 2 4 8. COMP / OTC*. MEDICAL 2 4 8 3 7. EACH PERSON $. PAYMENTS 3 7 2 4 8. SPECIFIED. BI CAUSES OF LOSS*. 2 6 CSL EA PER $ 3 7. UNINSURED. 3 7 BI EACH ACCIDENT $ 2 4 8. MOTORIST COLLISION. 4 3 7. BI. 2 6 CSL EA PER $ TOWING 3. UNINSURED / $. UNDERINSURED 3 7 BI EACH ACCIDENT $ & LABOR 7. MOTORIST. 4. 2 6. UNINSURED. 3 7 PROPERTY DAMAGE $. MOTORIST.

2 4. YES STATES COST OF HIRE IF ANY BASIS STATES # DAYS # VEH COVERAGE / DEDUCTIBLE. HIRED / BORROWED. LIABILITY NO $ COMP $. YES STATES HIRED SPEC. GROUP TYPE NUMBER OF C OF L $. PHYSICAL. NO EMPLOYEES COLL $. NON-OWNED DAMAGE. LIABILITY VOLUNTEERS. PARTNERS COVERAGE IS: PRIMARY SECONDARY. 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. ENDORSEMENTS / REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required). SIGNATURE. PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR INSURANCE.

3 AND SUBSEQUENT RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY. IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL. INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR. PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A. REQUEST TO US. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APLICATION FOR INSURANCE. CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL. THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.

4 I UNDERSTAND THAT NORTH CAROLINA LAW REQUIRES THAT MY POLICY MUST INCLUDE UNINSURED MOTORIST BODILY INJURY COVERAGE WITH LIMITS EQUAL. TO THE HIGHEST LIMITS OF BODILY INJURY COVERAGE ON ANY VEHICLE INSURED UNDER MY POLICY. HOWEVER, SUCH UM LIMITS ARE NOT REQUIRED TO. EXCEED $1,000,000 PER ACCIDENT, EVEN IF THE BODILY INJURY LIMITS ARE HIGHER. I ALSO UNDERSTAND THAT MY POLICY MUST INCLUDE UNDERINSURED. MOTORIST COVERAGE IF MY BODILY INJURY COVERAGE IS GREATER THAN THE BODILY INJURY LIMIT REQUIRED BY LAW. I ALSO UNDERSTAND THAT I AM. ALLOWED TO PURCHASE GREATER OR LESSER LIMITS AS PERMITTED BY LAW. I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND. CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING. APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER.

5 ACORD 137 NC (2010/02) Page 1 of 3 1996-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD. Clear All AGENCY CUSTOMER ID: TRUCKERS SECTION. PHYSICAL DAMAGE. COVERAGES COVERED AUTO SYMBOLS LIMITS * Include the Fire District name and code # if fire or COMP / OTC coverage is provided BI COVERED. 41 47 CSL EA PER $ COVERAGES AUTO SYMBOLS LIMITS DEDUCTIBLE. 42 50 BI EACH ACCIDENT $ 42 47. LIABILITY. 43 PROPERTY DAMAGE $ COMP / OTC* 43 $. 46 46. MEDICAL 42 46 42 47 SCL FT LSP. EACH PERSON $ SPECIFIED. PAYMENTS 43 43 F FTW $. CAUSES OF LOSS*. BI. 42 46 CSL EA PER $ 46. UNINSURED. 43 BI EACH ACCIDENT $ 42 47. MOTORIST. 45 COLLISION 43 $. BI. 42 46 CSL EA PER $ 46. UNINSURED /. UNDERINSURED 43 BI EACH ACCIDENT $ TOWING 46. MOTORIST $. 45 & LABOR. TRAILER INTERCHANGE.

6 42 46 * Include the Fire District name and code # if fire or COMP / OTC coverage is provided UNINSURED FARTH. 43 PROPERTY DAMAGE $ COVERAGES SYMBOL # TRAILERS ZONE # DAYS RADIUS DEDUCTIBLE. MOTORIST. 45 48. COMP / OTC*. YES STATES COST OF HIRE IF ANY BASIS 49. NON-TRUCKERS. HIRED / BORROWED NO $ 48. SPECIFIED. TRUCKERS YES STATES COST OF HIRE IF ANY BASIS CAUSES OF LOSS* 49. HIRED / BORROWED. LIABILITY NO $ 48. COLLISION $. YES STATES GROUP TYPE NUMBER OF 49. NON-OWNED NO EMPLOYEES STATES # DAYS # VEH. AUTO. LIABILITY VOLUNTEERS. PARTNERS HIRED. PHYSICAL. OTHER. DAMAGE. COVERAGE IS: PRIMARY SECONDARY. OTHER. COVERED AUTO SYMBOLS (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 ONLY ANOTHER TRUCKER UNDER A TRAILER.

7 (42) OWNED AUTOS ONLY COMPULSORY UNINSURED (48) TRAILERS IN YOUR POSSESSION UNDER INTERCHANGE AGREEMENT. (43) OWNED COMMERCIAL AUTOS ONLY MOTORIST LAW A TRAILER INTERCHANGE AGREEMENT (50) NON-OWNED AUTOS ONLY. ENDORSEMENTS / REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required). SIGNATURE. PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR INSURANCE. AND SUBSEQUENT RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY. IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL. INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR.

8 PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A. REQUEST TO US. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APLICATION FOR INSURANCE. CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL. THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES. I UNDERSTAND THAT NORTH CAROLINA LAW REQUIRES THAT MY POLICY MUST INCLUDE UNINSURED MOTORIST BODILY INJURY COVERAGE WITH LIMITS EQUAL. TO THE HIGHEST LIMITS OF BODILY INJURY COVERAGE ON ANY VEHICLE INSURED UNDER MY POLICY. HOWEVER, SUCH UM LIMITS ARE NOT REQUIRED TO. EXCEED $1,000,000 PER ACCIDENT, EVEN IF THE BODILY INJURY LIMITS ARE HIGHER.

9 I ALSO UNDERSTAND THAT MY POLICY MUST INCLUDE UNDERINSURED. MOTORIST COVERAGE IF MY BODILY INJURY COVERAGE IS GREATER THAN THE BODILY INJURY LIMIT REQUIRED BY LAW. I ALSO UNDERSTAND THAT I AM. ALLOWED TO PURCHASE GREATER OR LESSER LIMITS AS PERMITTED BY LAW. I UNDERSTAND THAT THE COVERAGE SELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS AND. CHANGES UNLESS I NOTIFY YOU OTHERWISE IN WRITING. APPLICANT'S SIGNATURE DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER. ACORD 137 NC (2010/02) Page 2 of 3. Clear All AGENCY CUSTOMER ID: MOTOR CARRIER SECTION. PHYSICAL DAMAGE. COVERAGES COVERED AUTO SYMBOLS LIMITS * Include the Fire District name and code # if fire or COMP / OTC coverage is provided BI COVERED. 61 67 CSL EA PER $ COVERAGES AUTO SYMBOLS LIMITS DEDUCTIBLE.

10 62 68 BI EACH ACCIDENT $ 62 67. LIABILITY. 63 71 PROPERTY DAMAGE $ COMP / OTC* 63 68 $. 64 64. 62 67 SCL FT LSP. SPECIFIED. 63 68 F FTW $. CAUSES OF LOSS*. 64. MEDICAL 62 64 62 67. EACH PERSON $. PAYMENTS 63 67 COLLISION 63 68 $. BI. 62 66 CSL EA PER $ 64. UNINSURED. 63 67 BI EACH ACCIDENT $ TOWING 63. MOTORIST $. 64 & LABOR 67. BI TRAILER INTERCHANGE. 62 66 CSL EA PER $ * Include the Fire District name and code # if fire or COMP / OTC coverage is provided UNINSURED /. FARTH. UNDERINSURED 63 67 BI EACH ACCIDENT $ COVERAGES SYMBOL # TRAILERS ZONE # DAYS RADIUS DEDUCTIBLE. MOTORIST. 64 69. COMP / OTC*. 62 66 70. UNINSURED. 63 67 PROPERTY DAMAGE $ 69. MOTORIST SPECIFIED. 64 CAUSES OF LOSS* 70. YES STATES COST OF HIRE IF ANY BASIS 69. NON-TRUCKERS. COLLISION $. HIRED / BORROWED NO $ 70. TRUCKERS YES STATES COST OF HIRE IF ANY BASIS STATES # DAYS # VEH.