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~_ <br />o~ <br />= A. p~ (hi•. •arpplunmm by i15n1} is not a comp.lor¢ policy of insurance and is nlfertive only when ,vllactiud to a CGA, AGC or AGL r.olrry, <br />~~~:-ref= G,r;~~~~.~„L,9~~ E~n~Y~l~~l ~~~~~7~~~ 96v~;~~fIL~~E ~~J~le~~~r_71;C.~T <br />s~,u _o <br />~_.. ._ <br />The insurance affordaJ for rsmh automobile is only with r¢slaa to such of 11ie lotlvwing roverages as are indica4d by spccilic prcmiwn charge. 71 ~: limit <br />of Th¢ W!;lu li: liability against exh such cov¢rag¢ shall M: as st atcd in the schcdul¢, subject to all the teens of this supplement having lefrr¢nce tbc•eto. <br />' SCHEDULE <br /> <br />Ye <br />r M <br />tlel - Tr <br />N <br />m <br />Id <br />ti (i <br />tl <br />-B <br />d <br />T <br />i Factory Lirt <br />P <br />i <br />O Actual Cort <br />P <br />Vfh Purdra:ed <br /> <br />:o. Garngo Location en <br />e <br />o <br />a <br />e <br />a <br />e <br />o <br />y <br />ypa - <br />cat <br />on, <br />Motor or Serial Number Aete-Glees r <br />r <br />ce <br />Rale Symbol <br />& Ago Group an <br />ur- <br />clr esvd Inc. <br />Equipment <br /> <br />Mo. Yr. <br /> <br />N ~ V <br />,: X13 <br />LaD =:1+~~D <br />1979 Chew. 4 a 4 CP,K149P478344 <br />6 <br /> --- <br /> <br />4. <br />5. _ - <br />6. - - <br />]. --_ _- <br />B. <br />9. <br />10. <br />COVERAGES AND PREMIUMS <br /> <br />D E - Collision F ~ <br />• <br />Ite <br />No. Botlily <br />Injury <br />Liability Property <br />Damage <br />Liability Automobile <br />Medical <br />PaYrnents <br />PIP Limit of Liability <br />(Gov. D, F, G, H & II Compre <br />h¢nsrve Detluctibl0 <br />gmpunt <br />Premium Fire <br />C' <br />Theh H <br />N'ind t <br />CAC •,,..s a <br />tmo~ c+.n <br />f]•. •.. <br />o.¢--.m K <br />U.M. <br />t <br />107.5 <br />feel. <br />l.oo -- - _- <br />s.o~ <br />z. <br />3. <br />4. -- <br />5. <br />6. <br />]. <br />8. <br />9. - <br />10. <br /> 1!?7. incl. 7epg xxxxxxxxxx XxxxX S.GO <br />'Automobile Liability, PIP, PPI, U.M. and Medical Payments Coverages are not provided in this su pptement but premiums fur such applicable'.: nv, nid <br />automobiles may be itemized herein. 10-28'83 d~ <br />Less Payee. lname and add res5) <br />Policy No. Named Insured- $upp' meet E(IECt rve __ <br />ilia Limit of Liabibty for Coverage E, Colision, shall he ACV wUlra to the dni uct- <br />ihle indicated. ACV, wherc~rer us,.d in this uhedule, means Actual Cosh Value.. ~ ~-_ . _ __ <br />ArrrF nrivM AnnN <br />