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HomeMy WebLinkAboutInsurance Certificate: Twedells Automotive Towing & Wrecking Inc (2) TWEDE-1 OP ID: RODO 81/201 2015 AC(7R0° CERTIFICATE OF LIABILITY INSURANCE 0110 DYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CON ACT NAME: Donna Rova N W Insurance Solutions, Inc PHONE FAX DBA American Insurance Agency lac. No. EMr.541-687-1915 ~Lc~Nol:1-687-0277 2677 Willakenzie Rd # 8 E-MAIL Eugene, OR 97401 SS; donna@nwinss0lutions.COm - Jim Rova INSURERS AFFORDING COVERAGE NAIC # INSURERA:Markel Insurance Compan~_ _ _ INSURED Twedell's Automotive, Towing & INSURER B:i Wrecking, Inc INSURER C : 3116 N Pacific Highway - Medford, OR 97501 INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EPP POLICY EXP - LIMITS LTR POLICY NUMBER MM/DD/YYYY MWDDNYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000100 A ~X COMMERCIAL GENERAL LIABILITY 8502RBOI1022 01/02/2015 0110212016 PREMISES Ea occurrence) $ 10_0,00 L17 CLAIMS-MADE I X I OCCUR MED EXP (Any one person) $ 5,00 H PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE _ $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. I PRODUCTS - COMP/OP AG_G $ 1,000,00 X7 POLICY PRO 7 LOC $ 17 JECT AUTOMOBILE LIABILITY j COMEaBINED SINGLE LIMIT 1,000 _ ,00 I accident) A ANY AUTO ! 18502RB011022 _ _ 01/02/2015 01/02/2016 BODILY INJURY (Per person) 1 ALL OWNED Xl' SCHEDULED I I I AUTOS AUTOS BODILY INJURY (Par accident) $ X HIRED AUTOS X AUTOS NON-OWNED I PER ACCIDEDNnTtAGE Is rI UMBRELLA LIAR OCCUR j EACH OCCURRENCE $ I EXCESS LIAR r + I ~ I _ -CLAIMS-MADE I AGGREGATE $ r I DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N I A I E.L. EACH ACCIDENT ! $ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under ( DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT A On Hook/Cargo I 1502RB011022 01/0212015 01/02/2016 $1000 ded 50.00 A 1Garagekeepers 8502RB011022 01/0212015 01/0212016 $1000 ded 500,000 bk DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER CANCELLATION ASHLA-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ashland Police Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 20 E Main St Ashland, OR 97520 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD OP ID: RODO DATE ACDRDL, VEHICLE SCHEDULE 1/8/2015 PRODUCER PHONE APPLICANT _I~vc ►o_rxc+: 541_6~Z-191$ ~r- (Flrss N W insurance Solutions, Inc Na=d Twedell's Automotive, Towing & Insured) DBA American Insurance Agency 2677 Willakenzie Rd # $ EFFECTIVE OATS EXPIRATION DATET DIRECT BILL PAYMENT PLAN AuD1T Eugene, OR 97401 _01102115 _ 01/02/16 X { AGENCY BILL ~i- Jim R©Va FOR COMPANY - - - --r- - _ USE ONLY _CODE: SUB CODE: AGENCY CUS70MERID TWEDE-1 VEHICLE DESCRIPTION BODY SYWAGE COST NEW TLIC KE: CheV1~TYPE', - 1, 1992 M0DE4: Wrecker _ v.IPE 1GCGK24F6NE181151 $ 11EN# YEAR MA ! SIC FACTOR SEAT CPT RADIUS FARTHEST TERM TERR ~GVW/GCW CLASS CITY, STATE, STATE ZIP WHERE j GARAGED DRIVE TO USE CHECK ADD'L NO- UNDRINS F LSP DEDUCT7gLE- S j ACV COMP SPEC MISC WORi(/SCHOOL COMM'L COVERAGES FAULT MOTOR I_ I-~C OF L~DRICR~_ - ` ! { 15 MILES _ PLEASURE RETAIL LA MEp PAY TOWING & LABOR FT COMP j AA L J ST AMT I $ ~1 TOTAL PREM FTW LOLL $ $ COLO $ - )1 15 MILES, f FARM SERVICE NO- UNINS SPEC I BODY SYMIAGE COAT NEW VEH N YEAR I, MAKE: Interntion _ TYPE: 1 2 1988 ~ MODEL: Wrecker v.1.N.: 1 HSZEGGRlJH592637 - -T--r---_-1 _ -r LIC TEI TERR GVW/GCWLASS 1 SIC FACTOR~SEATCPi RADIUS FARTHEST TERM CITY, STATE, STA ZIP WHERE GARAGED DRIVE TO CHECK ADD'L NO- UNDRINS DEDUCTIBLES CV COMP SPEC MISC WORKISCHOOL USE COMMT COVERAGES FAULT' MOTOR F LSP C OF L DR/CR: T TOTAL PREM MED PAY gOWI LggOR FT COMP AA ST AMT $ < 15 MILES PLEASURE RETAIL LIAB NG _1 115 MILES + FARM SERVICE NO- UNINS SPEC FTW COLL $ $ COLL $ MOTOR C OF I VEH p YEAR MAKE: Ford 704 SYM/AGE COST NEW 3 2004 MODEL: Wrecker v.1.N.: 1FTWX33PD4EA52849 $ - CITY, STATE, STATE TERR GVWlGCW CLASS I SIC I FACTOR SEAT CP RADIUS FARTHEST TERM ZIP WHERE GARAGED I I _ - - - DRIVE TO USE COMM'L CHECK ADD'L NOT UNDRIN-ST-- ~DIIEDUCTlBLES IC OF L DR/CR: WORK/SCHOOL I{.~. OVERAGES FAULT + MOTOR F LSP ACV COMP] ISPEC MISC < 15 MILES PLEASURE(' I RETAIL LIAB { MED PAY & LABOR FT COMP AA ~J ST AMT j_S TOTAL PREM 15 MILES * FARM { SERVICE NO- UNINS SPEC F COLL $ $ DOLL $ FAUI.T MOTOR C OF VEH l1 YEAR MAKE: Chevy _ TYPE: ~SYMIAGE COST NEW 4 1995 MoDEL: Rollback V.I.N.: 1GBKC34F8SJ103958 I $ _ CITY, STATE, STATE TERR^ GVWIGCW y CLASS SIC FACTOR ISEATCP RADIUS FARTHEST TERM ZIP WHERE f GARAGED I - DRNE TO CH''-- ECK ADD'L NO- UNDRINS DEDUCTIBLES SPEC MISC WORK/SCHOOL USE JCOMM" COVERAGES I FAULT MOTOR F LSP _ ACV COMP I _.C OF L DR/CR: TOWING TOTAL PREM 1 < 15 MILES PLEASURE ! RETAIL LIAB MED PAY g LABOR FT COMP AA ST AMT $ NO- UNINS SPEC { 15 MILES + FARM SERVICE I FTW COLL $ $ COLL $ VEH # YEAR II BODY SYM/AGE COST NEW MAKE: Sterling-4TYPE: I 5 - i 2001 MODEL: Wrecker _ w.LNl2FZAAKAK41AJ1861_2 CITY, STATE, 41.E&ES ATEI TERR GVWiGCW CLASSSIC FACTOR SEATCPRADIUS FARTHE5TTERM ZIP WHERE GARAGED DRIVE TO USE ADD'L NO- UNDRINS DEUCTIBLEACVSPEC MISC _WORK/SCHOOLGOMM'L FAULT MOTOR F LSP G OF L DR/CR: 15 MILES PLEASURE RETAIL MEp PAY TOWING L BOR FT COMP AA Lj ST AMT $ TOTAL PREM 15 MILES + FARM SERVICE NO UNINS SPEC I FTW DOLL $ $ DOLL $ FAULT MOJOR _0 L VEH # L2OOO BODY SYMIAGE COST NEW MAKE. Ford TYPE: 6 MO DEL: Wrecker v.I._N.: 1 FDAF56FBYEE27691 $ TERR CVW/GCW CLASS 5 1C FACTOR SEAT CP RADIUS FARTHEST TERM CITY, STATE, STATE LP WHERE GARAGED DRIVE TO USE CHECK ADD'L NO- UNDRINS F LSP DEDUCTIBLES CV COMP SPEC MISC WORK/SCHOOL COMM'L COVERAGES FAULT MOTOR C OF L! CR/CR: _ < 15 MILES 1 PLEASUREI RETAIL LIAB MED PAY g LpgpR FT COMB AA ; ST AMT ! $ TOTAL PREM NO- UNINS SPEC 15 MILES + FARM SERVICE I FTW { COLL $ COLL $ VENN 1 YEAR I MAKE: Internati0 TB'yODY SYMIAGE COST NEW 4- z 7 2004 MODEL: Rollback v.LN.: 1HTMMAAL94H656972 _ $ --T---- LIC _T CITY, STATE, STATE 7ERR GVW/GCW CLASS _ I SIC FACTOR ISEATCPRADIUS ? FARTHEST TERM ZIP WHERE GARAGED SPEC MISC DRIVE T WORK/SCHOOL USE COMM'LCHVERAGES FAULTNp MOTORS F LSP DEDUCTIBLES C OF L DR/CRACV. ,COMP TOWING TOTAL PREM < 15 MILES PLEASURE RETAIL LIAB UN MED NSAY SPEC LABOR FT COMP AA LJi ST AMT 15 MILES + FARM SERVICE FTW COLL $ I$-- COLL $ ACORD 129 (1198) CQACORDCORPORATIOM993 OP ID: RODO ACORD,, VEHICLE SCHEDULE 1/8%2015 PRODUCER PHONE APPLICANT a No >nJ_541-687.1915___ (First N W Insurance Solutions, Inc Named Twedell's Automotive, Towing & DBA American Insurance Agency Insured) 2677 Willakenzie Rd # 8 EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT Eugene, OR 97401 I Jim Rova _01102/15 01/02116 HX AGENCY BILL FOR T - COMPANY CODE: _~$US CODE: USE ONLY AGENCY CUSTOMER ID TWEDEA VEHICLE DESCRIPTION VEH # YEAR MAKE: Intefnatl0 WD SYMIAGE COST NEW TYPE: 8 1999 MooEL: Wrecker - v.I.N.: 1HTSCAAM--XXXXH6812.39 $ _ CITY, STATE, i (STATE 1ERR GVW/GCW :LASS SIC FACTOR SEATCP1 RADIUS FARTHESTTERM ZIP WHERE GARAGED DRIVE TO USE CHECK ADD'L NO- UNDRINS DEDUCTIBLES SPEC MISC WORKISCHOOL COMM'L COVERAGES FAULT _ MOTOR F LSP ACV _j COMP L-IC OF L DR/CR: y < 15 MILES PLEASURE, RETAIL i LIAR MED PAY r g LABOR I j FT COMP AA ST AMT ` $ 1 TOTAL PREM 7 r NO- UNINS SPEC --1 15 MILES + FARM SERVICE I FTW COLL $ $ COLD $ VEH # i YEAR 1 MAKE: Ford BOPS SYMIAGE , COST NEW _ 9 _L 2008 MODEL: Wrecker v.1-N.:_ 1 FTXW43R38ED59002 I $ T---1 CITY, STATE, ST TERR GVW/OCW CLASS i SIC FACTOR iSEATCP RADIUS TFARTHEST TERM ZIP WHERE ~ GARAGED DRIVE SC USE CHECK ADD'L NO- UNDRINS DEDUCTIBLES SPEC MISC WORK/SCHOOL COMM'L COVERAGES FAULT MOTOR F LSP ACV COMP C OF L DR/CR: TOWING _ < 15 MILES I PLEASURE RETAIL LIAB MED PAY & LABOR FT jCOMP AA ST AMT TOTAL PREM 15 MILES + I FARM SERVICE NFAI 11 T MOTOR H O- UNINS SPEC FTW COLL $ $ COLD $ VEH # YEAR MAKE: Edzu TYPE SYM/AGE COST NEW 10-~ 2006 MoDEL: Trailer _ - T V.I.N.: 5H2812LP85WO11773 $ - CITY, STATE, STAB TERR GVW/GCW CLASS SIC FACTOR SEATCP RADIUS FARTHEST TERM- ZIP WHERE GARAGED I I DRIVE TO USE , -r CHECK ADD'L NO- UNDRINS DEDUCTIBLES SPEC MISC WORK/SCHOOL L ~COMM'L COVERAGES FAULT MOTOR I F )LSP _ _JACVj_tCOMP COFL.DR/CR:_ < 15 MILES PLEASURE RETAIL I LIAB MED PAY & TOWING LABOR FT COMP J AA 1 ST AMT I $ _ TOTAL PREM HC OF L HI 15 MILES-. FARM I SERVICE NO- UNINS SPEC fTW COLL $ $ COLLI $ VEH # YEAR MAKE: BI T BODY TYPE: SYMIAGE COST NEW 11 2003 1 MODEL: Trailer V.I.N.: 16VCX182531 E59"O $ CITY, STATE, LIC TERR GVWIGCW CLASS SIC FACTOR JSRADIUS FARTHESTTERM ZIP WHERE STATE GARAGED DRIVE TO USE COMM'L CHECK ADD'L NO- UNDRINS SPEC MISC WORK/SCHOOL _ F LSP ACV COMP COVERAGES i FAULT MOTOR DEDUCTIBLES _JC OF L DR/CR: TOWING TOTAL PREM < 15 MILES ,PLEASURE RETAIL LIAB MED PAY & LABOR _ FT COMP AA ST AMT $ - FAU1 MOTOR r. QE I O- UNINS SPEC FTW COLL $ $ COLL $ 15MILES + FARM SERVICE N VEH# YEAR BODY ! MAKE: Haul V - TYPE: SYMIAGE 1 COST NEW 12 2003 1 MODEL: Tr_aile_r_ I V.I.N.: 16HCB121X3UO30971 CITY, STATE, J - ISTIC TERR GVW/GCW - ? CLASS SIC I FACTOR SRADIUS FARTHEST TERM ZIP WHERE GARAGED DRIVE TO T USE CHECK ADD'L NO- UNDRINS DEDUCTIBLES ~~SPEMISC W RK/SCHOOL I COMM'L COVERAGES FAULT MOTOR F LSP _ ACV COMP IC OF LI DR/CR: _ 15 MILES PLEASURE) RETAIL _ LIAB MEO PAY TOWING L & LABOR FT COMP I AA J ST AMT $ TOTAL PREM 115 MILES + FARM I SERVICEF NO UNINS SPEC FTW r FAI H COLL $ J $ COLD $ OF - vEH # YEAR MAKE: Roadrunner BODY TYPE: SYMIAGE COST NEW 13 12006 MoD_EL: Trail_er_ V.I.N.: SUOSC1016R000810 v~ $ CITY, STATE, LIC TERR GVW/GCW CLASS SIC FACTOR SRADIUS I FARTHESTTERM ZIP WHERE STATE GARAGED DRIVE TO USE CHECK W ; ADD'L NO- UNDRINS SPEC MISC ORKISCHOOL Ir COMM'L C VERAGES FAULT, MOTOR F _LSP DEDUCTIBLES _ ACV COMPiJCOFL < 15 MILES I PLEASURE!_ RETAIL LIAB MED PAY T IpR FT COMP AA ST AMT 1 $ I TOTAL REM J{ I NO- UNINS SPEC 15MILES + I FARM SERVICE FAULT MOTQR C FL FTW COLL $ i$ COLL $ VEH YEAR MAKE: Internatio TYPE SYMIAGE COST NEW 14 2005 MODEL: Trailer V.I.N.: 4RAC518285NO32236 ~ I $ CITY, STATE, LIC' TERR GVW/GCW CLASS SIC FACTOR SEATCP RADIUS FARTHEST TERM ZIP WHERE STATE GARAGED DRIVE TO USE CHECK ADD'L NO- UNDRINS DEDUCTIBLES SPEC MISC WORK/SCHOOL COMM'L COVERAGES FAULT MOTOR F hILSP ACV COMP C OF L DRICR: TOWING TOTAL PREM < 15 MILES PLEASURE RETAIL LIAB MED PAY g LABOR FT COMP AA ST AMT $ NO- UNINS SPEC 15 MILES + FARM SERVICE FAU T H MOTOR C OF L FTW COLL $ Is COLLI $ ACORD 129 (1198) CACORDCORPORATION1993 OP ID: RODO ACORD,, VEHICLE SCHEDULE 1/8/2015 PRODUCER I P1~CNNo. Ext)A1_687-1915 - APPLICANT Na N W Insurance Solutions, Inc nwd Twedell's Automotive, Towing & tosaredi DBA American Insurance Agency _ 2677 Willakenzie Rd # 8 uF-ECmrE DATE EXPIRATION DATE DIRECT BILL- PAYMENT PLAN AUDIT Eugene, 97401 01/02115 01/02_/_16_'1 X I AGENCYBILL Jim Rova FOR - COMPANY CODE: _ SUB CODE: _ USE ONLY AGENCY CUSTOMER ID TWEDE-1 VEHICLE DESCRIPTION NEW VEH # YEAR MAKE: TP BODY SYWAGE COST D _ _TYPE: 15 1998 MODEL: Trailer _--~-V.I.N.: MC29033W1090148 $ _ CITY, STATE, STATE TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM ZIP WHERE GARAGED DRIVE TO CHECK ADD'L NO- UNDRINS pEDUCTIBLES SPEC MISC WORK/SCHOOL USE COMM'L 'COVERAGES FAULT MOTOR F LSP ACV COMP L ~C OF L DRICR: I 71 TOWING TOTAL PREM < 15 MILES PLEASURE: RETAIL _LIAB MED PAY & LABOR FT COMP L~ AA ST AMT . $ 15MILES + 7-1; FARM ~ (SERVICE NO- j UNINS SPEC FTVY COLE $ $ COLE $ FAULT MOTOR Q OE L VEH # I YEAR BODY SYMIAGE , COST NEW MAKE TYPE: - MODEL: V.I.N.: $ CITY, STATE, LIC TERR GVWIGCW CLASS T SIC FACTOR SEAT CP RADIUS FARTHEST TERM ZIP WHERE STATE GARAGED DRIVE TO USE ADD 'L NO- UNDRINS DEDUCTIBLES SPEC MISC WORKISCHOOL COMM'L CHECKCOVERAGES FAULT MOTOR F LSP ACV COMP ! C OF L DR/CR: A TOWING A TOTAL PREM < 15 MILES PLEASURE RETAIL LIAB MED PAY & LABOR FT COMP AA ST AMT $ 15 MILES + FARM SERVICE NO- I UNINS SPEC FTW COLE $ $ COLE $ VEH # 1 YEAR BODY SYMIAGE COST NEW MAKE: - - TYPE: MODEL: $ CITY, STATE, STATE TERR GVW/GCW -T CLASS SIC FACTOR i SEAT CP RADIUS 1 FARTHEST TERM ZJP WHERE I GARAGED DRIVE TO USE ` CHECK ADD'L NO- UNDRINS IDP EDUCTIBLES SPEC MISC WORKlSCHOOL~ _ COMM'L COVERAGES FAULT R MOTOR I F LS-~ - CVF~COMP JC OF L DIi/CR:_ _ < 5 MILES A PLEASUREi RETAIL LIAB MED PAY gOj A~gOR FT COMAA ST AMT $ TOTAL PREM 1 15 MILES FARSERVICE NO- UNINS SPEC FTW COL~$ COLE $ VEH # YEAR MAKE: BODY SYMIAGE COST NEW - TYPE: -1 MODEL: V.I.N.: $ LIC CITY, STATE, STATE TERR GVW/GCW CLASS SIC FACTOR ISEATCP RADIUS FARTHESTTERM ZIP WHERE GARAGED DRIVE TO USE CHECK ADD 'L NO- UNDRINS DEDUCTIBLES SPEC MISC W RK/SCHCOL _ COMM'L C VERAGES FAULT MOTOR F _ LSP ACV _]COMP OF L DR/CR.- TOWING i AA ST AMT $ TOTAL PREM < 15 MILES PLEASURE RETAIL LIAB MED PAY & LABOR FT ~JCOMP NO- UNINS SPEC 15 MILES + FARM SERVICE FTW COLE $ $ COLE $ VEH # YEAR BODY SYMIAGE COST NEW MAKE: - T TYPE:^--_ MODEL: _j CITY, STATE. S AlE TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM ZIP WHERE GARAGED C DRIVE TO USE CHECK ADD'L NO- UNDRINS DEDUCTIBLES SPETLDPJ" WORKISCHOOL 1 h I COMM'L I COVERAGES FAULT MOTOR F H LSP ACV -(COMP L-1 OCR: < 1 5 MILES TOWING PLEASURE' RETAIL LIAB MED PAY g Lp BOR FT COMP AA ST AMT $ AL PREM 15MILES+ FARM SERNOUNINS SPEC p COLE $ $ COVEH # YEAR MAKE: BODY SYMIAGE COST NEW TYPE: MODEL: V.I.N.: $ CITY, STATE, LIC TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS I FARTHEST TERM ZIP WHERE STATE GARAGED DRIVE TO USE CHECK ADD'L NO- : UNDRINS DEDUCTIBLES SPEC MISC WORK/SCHOOL L-_ ~OMM'L COVERAGES~FAULT ~ MOTOR F %LSP -4 ,AGV COMP,- _ C OF L _DRIICR_ I TOWING r TOTAL PREM < 15 MILES PLEASURE ~I RETAIL _ LIAB MED PAY & LABOR FT COMP AA ST AMT $ 15 MILES + I FARM SERVICE NO- UNINS SPEC FTW COLE $ $ COLL $ VEH # YEAR BODY ' SYMIAGE COST NEW MAKE: I IYPE_--- MODEL: V_I.N.: Is _ CITY, STATE, STATE TERRA GVW/GCW CLASS SIC FACTOR iS~EATCP RADIUS FARTHESTTERM ZIP WHERE 1 GARAGED DRIVE TO USE CHECK ADD'L NO- UNDRINS DEDUCTIBLFST SPEC MISC WORK/SCHOOL COMM'L COVERAGES FAULT MOTOR F LSP ACV COMP C OF L DR/CR: < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING TOTAL PREM & LABOR FT COMP AA MT p, FAULT "OT, I H COF FARM SERVICE NO- UNINS SPEC FTW COLL $ Is COLLI $ 15MILES + ACORD 129 (1/98) CACORDCORPORATION1993