VEHICLE SCHEDULE
Date (MM/DD/YYYY):
AGENCY:
CARRIER:
NAIC CODE:
POLICY NUMBER:
EFFECTIVE DATE:
NAMED INSURED(S):
VEH #
YEAR
MAKE
BODY TYPE
VEHICLE TYPE
SYM/AGE
COMP/OTC SYM
COLL SYM
PPSPECCOML
MODEL:
V.I.N.:
GARAGING ADDRESS
STREET (Required in KY)
CITY
COUNTY
STATE
ZIP
LIC STATE
TERR
GVW/GCW
CLASS
SIC
FACTOR
SEAT CP
RADIUS
FARTHEST TERMINAL
COST NEW:
USE
CHECK COVERAGES
DEDUCTIBLES
COMP/OTC
PleasureFarmRetailServiceFor Hire
LiabilityMed PayUninsured Motorist
$ AA, $ St Amt
$
DRIVE TO WORK / SCHOOL
< 15 MILES
15 MILES +
NET VEH DR/CR:
TOTAL PREM: $
MAKE:
BODY TYPE:
PP SPEC COML
GARAGING ADDRESS STREET (Required in KY)
GVW / GCW
COST NEW
Pleasure Pleasure
Farm Farm
Retail Retail
Service Service
COMM’L Yes
FOR HIRE Yes
Liab Liab
No-Fault No-Fault
Med Pay Med Pay
Unins Motor Unins Motor
AA $
ST AMT $
ACV $
COMP/OTC $
SPEC C OF L $