VEHICLE SCHEDULE

    Date (MM/DD/YYYY):

    AGENCY:

    CARRIER:

    NAIC CODE:

    POLICY #:

    EFFECTIVE DATE:

    INSURED:

    VEH #:

    YEAR:

    MAKE:

    BODY:

    TYPE:

    SYM/AGE:

    COMP/OTC:

    COLL:

    MODEL:

    V.I.N.:

    STREET:

    CITY:

    COUNTY:

    STATE:

    ZIP:

    LIC STATE:

    TERR:

    GVW/GCW:

    CLASS:

    SIC:

    FACTOR:

    SEAT CP:

    RADIUS:

    FARTHEST TERM:

    COST NEW:

    USE:

    Pleasure
    Farm
    Retail
    Service
    For Hire

    COVERAGES:

    Liability
    Med Pay
    Uninsured Motorist

    DEDUCTIBLES:

    AA $

    ST AMT $

    COMP/OTC: $