Drive-Away Application

1 Drive-Away ApplicationCOLUMBIA INSURANCE COMPANYNATIONAL FIRE & MARINE INSURANCE COMPANYNATIONAL INDEMNITY COMPANYNATIONAL INDEMNITY COMPANY OF MID-AMERICANATIONAL INDEMNITY COMPANY OF THE SOUTHNATIONAL LIABILITY & FIRE INSURANCE COMPANY Policy Term From: To (and "dba") G Individual/Proprietorship G Partnership G Corporation G OtherBusiness Phone Number Address City State Zip AddressCity State Zip to contact for inspection (name and phone number) you ever had insurance with one of the companies listed at the top of this page?

2 G Yes G NoIf yes, Policy Number(s) Effective Date(s) DESCRIPTION OF OPERATIONS business Years experience New Venture? G Yes G No this your primary business? G Yes G No If no, explain you ever filed for Bankruptcy? G Yes G NoIf yes, when Explain receipts last year Estimate for coming year Business for sale? G Yes G you operate in more than one state? G Yes G NoIf yes, list states you operate over a regular route? G Yes G No If yes, show towns operated between: LIABILITY COVERAGE Complete for desired coverages by indicating limits of (whereapplicable)PHYSICAL DAMAGEC ombined SingleLimit BI & PDSplit LimitsDeductiblesMaximumVehicleValueBodi ly InjuryProperty DamageG ComprehensiveG Spec.

3 C of LossCollisionEach PersonEach AccidentEach AccidentAPPLICABLE PERSONAL INJURY PROTECTION, uninsured AND/OR UNDERINSUREDMOTORISTS INSURANCE SELECTION/REJECTION PAGE IS REQUIRED TO BE COMPLETED ANDSIGNED BY THE NAMED INSURED WITH THE SUBMISSION OF THIS Application . DRIVER INFORMATION If additional space is needed, attach separate 's NameDate of BirthDriver's LicensesExperienceStateNumberClass/Type( CDL)YearsLicensed (inClass/Type)Type of Unit(Bus, Van,Truck,Tractor, etc.)No. ofYears1. INFORMATION (Continued) If additional space is needed, attach separate YearsPreviousCommercialDrivingExperience Date of HireAccidents and Minor Moving TrafficViolations in Past 5 YearsMajor Convictions(DWI/DUI, Hit & Run, Manslaughter, Reckless,Driving While Suspended/ Revoked, Speed Contest, other felony)Employee (E)Ind.

4 Cont. (IC)Owner/Op. (O/O)Franchisee (F)No. ofAccidentsDate(s)No. ofViolationsDate(s)Describe ConvictionDate(s) ATTACH DETAILED EXPLANATION OF ACCIDENTS LISTED ABOVE. M-4493c CA (07/2009) Drive-Away Application Page 1 of drivers covered by Workers Compensation? G Yes G No If yes, name of carrier years driving experience required drivers ever allowed to take vehicles home at night? G Yes G No If yes, will family members drive ? G Yes G No you order MVR's on all drivers prior to hiring? G Yes G No Driver's maximum driving hours daily, weekly you agree to report all newly hired operators?

5 G Yes G is the basis for driver(s) pay? G HourlyG Trip G MileageG Other, Explain LOSS EXPERIENCE Provide prior insurance carriers information for past full three TermInsurance Company NameNo. of MotorPoweredVehiclesNo. ofAccidentsPremiumTotal Amount Claims Paid & ReservesFromToLiabPhys DamBIPDComp/CollOther/ // // // // // any applicant aware of any facts or past incidents, circumstances or situations which could give rise to a claim under the insurance coveragesought in this Application ? G Yes G NoIf yes, provide complete details you ever been declined, cancelled or nonrenewed for this kind of insurance?

6 G Yes G No If yes, date and why Drive-Away INFORMATION20 Types of units driven away and percentages of each of the time you drive away new units: %used units: % physical damage coverage is desired, what is the average value per unit? What is the maximum value per unit? are you paid: G By MilesG By rate you are paid per mile per number of full-time drivers Total number of part-time you require insurance filings? G State G FHWA If FHWA filing, please provide MC number is return trip handled? delivery made with one unit towing another unit?

7 G Yes G NoDo you permit drivers to tow their own vehicles? G Yes G NoDo you haul away vehicles? G Yes G No Do you use any of the following: G Fifth wheel G Tow bars G Reese hitches G Ball towing a vehicle for return transportation, how often is this done? radius one-way Average radius one-way Estimated total annual total number of trips per week Do you deliver vehicles both ways? G Yes G and states where units are picked up city and state destinations clients operations other than Drive-Away service? G Yes G NoIf yes, explain Plate you required to use plates?

8 G Yes G No Do you use your own plates exclusively? G Yes G No Total number of plates What type of plates do you use? G Transporter G IRP G Other many plates are required to be attached to each unit drive away ? On average, how many of your plates are attached to Drive-Away vehicles at any given point? 38. How are plates returned to you? Average number of days before plates are returned? identification number for each plage all plates owned to be insured this policy? G Yes G NoIf no, explainAlso, if no, number of operators used?

9 Do operators have written contracts with you? G Yes G No ATTACHED COPY OF Passenger Drive-Away you drive away sports cars or luxury type units?G Yes G NoIf yes, list unit model(s) you tow a second client-owned vehicle?G Yes G NoBus of time units with the following seating capacities are driven away : under 20 % 21 and over %Truck/Tractor of time each unit type is driven away : trucks % tractors % tractors and trailers % trucks, percentage of each GVW driven away : 0-20,000 lbs % 20,001-45,000 lbs % 45,001+ lbs % you piggyback?

10 G Yes G No What percentage of time do you piggyback? % percentage of your piggyback operation is 1 up? % 2 up? % 3 up? % Drive-Away Application Page 2 of 5M-5394a (05/2009)CALIFORNIA uninsured MOTORISTS COVERAGESELECTION/REJECTION FORMDO NOT SIGN UNTIL YOU READU ninsured Motorists Coverage Option to RejectThe California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injuryliability insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motorvehicle.