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/N.: o ~. <br />t~ 9 <br />~ / ;'~1/I <br />`•..~~L 6 <br />L'a-r•d hswctl_ <br />DECLARATIONS SCHEDULE AUT01+tOBIIE LIABILITY EIAZAkD~ <br />AND AUTOMOBILE MEDIAL PAYMEN I S ENUORSCMENT <br />Eltect,ve Dale rssT-0Rnq~it'i~~ oT <br />COVERAGE F AUTOMOBILE MEDICAL PAYMENTS <br />SCHEDULE <br />Ep~ooesEtirE~,T - <br />- Author izetl Agdnt <br />Limit of Liability • S each person <br /> <br />Deslgr,alion of Aulomohi les -Division 1 De signaled Person Insured <br />Il) ~ Any owned automobile <br />121 C Any licensetl owned private passenger automobile <br />r31 [Any hcensetl awned automobile of the pickup, sedan tlelrvery or panel Type <br />'al I- Any hired aulomohile <br />Any aulomohile described •:nth speufrc Automobile Llzdical Payments premium charge <br />'71 ' <br />_ <br />~EI <br />___ __ _ _ <br />__ ___ _ _ _ _ __ <br />Description of Hazards Deposit Piemiu-s <br />Bodily Property ~ Put on <br />1. OWNED AUTOMOBILES Premium Bass - Pel Automobile <br />_ <br />Pm poses Injury Damage ~ Mad <br />P, loci pal Garage Location Year Llotlel Tiatle Kane and Body Type Motor. Ser ial of Ida old ~calion Id o. or Use' Liability Liability Payn <br /> <br />Per Attached Supp <br />ement <br />107.52 I <br />incl. <br />2. HIRED AUTOMOBILES Premium Basis -Cost of Hiie <br />Types Hued Location Where Auto Will Be Pr inc really Usetl Estimated Rates Pei 5100 <br /> Cost of Hne Casl of Hue <br /> 0. I. P. D. <br />class 6 guitar, Colorado f ary <br />Priv, pass altar, Colorado f any .114 ncl. <br />3. NON~OW'NED AUTOMOBILES Premum Basis -Class 1 Persons antl Class 2 Employees <br />Class 1 Peaons -Name of Each Local ion of Headquarters of Persons Nametl Rates P er Pelson 12.94 1nC1, <br /> B I, P. D. <br />If any Aguilar, Colorado .024 incl. <br />Class 2 Employees Location of Headquarters of Class 2 Employees Roles Per Employee <br />Eshmatetl Average Number B. I, P D <br />If an P. altar, Colorado .526 incl. <br />!.tim r. um Premiums ++ e. 1. S 12,94 <br />Divis,ons 2 8 3 f P D s incl. Sub~Tolals X124 4 `incl. s __ <br />Pr ei'~iwn loi Autn ro7ile Physical Damage Ins u: acce $u <br />AUTOMOBILE DEPOSIT PREMIUM <br />s 5 . CJl <br />s 7,n~ <br />S _ __ <br />S <br />132.46 <br />obile <br />ical <br />E 115 <br />FSB" ceans Firasve anc B.a rrzss~~. "C- r'ans 'Cc-'rrc is l" <br />F ei r~ AGC 1675 <br />onvonl r nr rnrr ~novt <br />