VEHICLE SCHEDULE

    Date (MM/DD/YYYY):

    VEH #

    YEAR

    MAKE

    BODY TYPE

    VEHICLE TYPE

    SYM/AGE

    COMP/OTC SYM

    COLL SYM

    GARAGING ADDRESS

    STREET (Required in KY)

    CITY

    COUNTY

    STATE

    ZIP

    LIC STATE

    TERR

    GVW/GCW

    CLASS

    SIC

    FACTOR

    SEAT CP

    RADIUS

    FARTHEST TERMINAL

    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: $

    VEH #

    YEAR

    MAKE:

    BODY TYPE:

    MODEL:

    V.I.N.:

    VEHICLE TYPE



    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

    COMM’L

    FOR HIRE

    CHECK COVERAGES

    DEDUCTIBLES

    AA $

    ST AMT $

    ACV $

    COMP/OTC $

    SPEC C OF L $