GEORGIA COMMERCIAL AUTO

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1 AGENCY GEORGIA COMMERCIAL / LIMITS SECTION NAMED INSURED(S) (MM/DD/YYYY) POLICY NUMBER EFFECTIVE CARRIER NAIC CODE BUSINESS SECTION SYMBOLS LIMITS 1 9 EA SYMBOLS LIMITS TRADITIONAL (REDUCED) NEW (AD ON) (IF APPLICABLE) N-OWNED SYMBOLS 6 6 (1) ANY () ALL OWNED S () OWNED PRIVATE PASSENGER S COST OF HIRE GROUP TYPE & LABOR () OWNED S THAN PRIVATE PASSENGER (5) ALL OWNED S WHICH REQUIRE -FAULT COVERAGE (6) OWNED S SUBJECT TO COMPULSORY U.M. LAW # DAYS # VEH COVERAGE / UCTIBLE COMP SPEC C OF L COLL COVERAGE IS: PRIMARY SECONDARY () S ON SCHEDULE () S (9) N-OWNED S SONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM SONS THAN YOU. SUCH INFORMATION AS WELL AS SONAL AND ANY SON WHO KWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ATHER SON FILES AN APPLICATION FOR INSURANCE I UNDERSTAND AND ACKWLEDGE THAT TRADITIONAL (REDUCED) COVERAGE AND, IF APPLICABLE, NEW (AD ON) COVERAGE HAVE BEEN OFFERED AND EXPLAINED TO ME. I HAVE SELECTED THE LIMITS AND UCTIBLE OPTIONS SHOWN IN THIS APPLICATION. RENEWALS, CONTINUATIONS AND CHANGES UNLESS I TIFY YOU WISE IN WRITING. APPLICANT'S PRODUCER'S ACORD 1 GA (009/0) Page 1 of ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD

2 TRUCKERS SECTION SYMBOLS LIMITS 1 6 EA SYMBOLS LIMITS UCTIBLE 50 6 SCL F FT FTW LSP & LABOR 6 6 N-TRUCKERS TRUCKERS N-OWNED COST OF HIRE COST OF HIRE GROUP TYPE 9 9 TRAILER INTERCHANGE SYMBOL # TRAILERS FARTH # DAYS RADIUS UCTIBLE ZONE 9 # DAYS # VEH COVERAGE IS: PRIMARY SECONDARY SYMBOLS (1) ANY () OWNED S ONLY () OWNED COMMERCIAL S ONLY () OWNED S SUBJECT TO -FAULT (5) OWNED S SUBJECT TO A COMPULSORY LAW (6) SPECIFICALLY DESCRIBED S () S ONLY () TRAILERS IN YOUR POSSESSION UNDER A TRAILER INTERCHANGE AGREEMENT (9) YOUR TRAILERS IN THE POSSESSION OF ATHER TRUCKER UNDER A TRAILER INTERCHANGE AGREEMENT (50) N-OWNED S ONLY SONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM SONS THAN YOU. SUCH INFORMATION AS WELL AS SONAL AND ANY SON WHO KWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ATHER SON FILES AN APPLICATION FOR INSURANCE I UNDERSTAND AND ACKWLEDGE THAT COVERAGE HAS BEEN OFFERED AND EXPLAINED TO ME. I HAVE SELECTED THE LIMITS AND UCTIBLE OPTIONS SHOWN IN THIS APPLICATION. RENEWALS, CONTINUATIONS AND CHANGES UNLESS I TIFY YOU WISE IN WRITING. APPLICANT'S PRODUCER'S ACORD 1 GA (009/0) Page of 5

3 MOTOR CARRIER SECTION SYMBOLS LIMITS N-TRUCKERS TRUCKERS N-OWNED COST OF HIRE COST OF HIRE GROUP TYPE EA TRAILER INTERCHANGE FARTH SYMBOL # TRAILERS ZONE # DAYS 0 0 RADIUS 0 SYMBOLS LIMITS UCTIBLE & LABOR 6 # DAYS COVERAGE IS: F FTW 6 6 # VEH SCL FT PRIMARY LSP UCTIBLE SECONDARY SYMBOLS (61) ANY (6) OWNED S ONLY (6) OWNED PRIVATE PASS S ONLY (6) OWNED COMMERCIAL S ONLY (65) OWNED S SUBJECT TO -FAULT (66) OWNED S SUBJECT TO A COMPUL- SORY LAW (6) SPECIFICALLY DESCRIBED S (6) S ONLY () TRAILERS IN YOUR POSSESSION UNDER A TRAILER INTERCHANGE AGREEMENT (0) YOUR TRAILERS IN THE POSSESSION OF ATHER TRUCKER UNDER A TRAILER INTERCHANGE AGREEMENT (1) N-OWNED S ONLY SONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM SONS THAN YOU. SUCH INFORMATION AS WELL AS SONAL AND ANY SON WHO KWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ATHER SON FILES AN APPLICATION FOR INSURANCE I UNDERSTAND AND ACKWLEDGE THAT COVERAGE HAS BEEN OFFERED AND EXPLAINED TO ME. I HAVE SELECTED THE LIMITS AND UCTIBLE OPTIONS SHOWN IN THIS APPLICATION. RENEWALS, CONTINUATIONS AND CHANGES UNLESS I TIFY YOU WISE IN WRITING. APPLICANT'S PRODUCER'S ACORD 1 GA (009/0) Page of 5

4 TRADITIONAL AND NEW COVERAGE MANDATORY OFFER AND EXPLANATION Georgia insurance law requires that we offer and explain to you Traditional Uninsured Motorist Coverage and if applicable, New Uninsured Motorist Coverage. Below is a brief description of each coverage option. Only the policy provides a complete description of coverage(s) and limitation(s). You have the right to select a specific coverage or reject all uninsured motorist coverage(s) in writing. Traditional Uninsured Motorist Coverage a/k/a Uninsured Motorist Coverage-Reduced by At-Fault Liability Limits pays for bodily injury and property damage losses to you and your passengers as a result of an accident with a driver who either has no liability protection and is legally responsible for the injuries or damages, or does not have enough protection to pay the full amount that the injured person is legally entitled to recover as damages. New Uninsured Motorist Coverage a/k/a Uninsured Motorist Coverage-Added on At-Fault Liability Limits pays for the same bodily injury and property damage losses as Traditional Uninsured Motorist Coverage, however; it provides additional protection that will pay for your damages in addition to the At-Fault driver's Liability Coverage Limits up to your New Uninsured Motorist Coverage Limits. This new coverage is available on vehicles qualifying as private passenger type vehicles under Georgia law. You have the right to purchase Traditional Uninsured Motorist Coverage or New Uninsured Motorist Coverage, if applicable, with limits up to the liability limits of your policy. Your selection coverage options are listed below: I accept Traditional Uninsured Motorist Coverage I accept New Uninsured Motorist Coverage I reject ALL Uninsured Motorist Coverage I acknowledge that I read and understand my Traditional Uninsured Motorist and/or New Uninsured Motorist Coverage, if applicable, options. Applicant's Signature Date ACORD 1 GA (009/0) Page of 5

5 Example of New Uninsured Motorist Coverage and Traditional Uninsured Motorist Coverage Claim Payment Calculation An underinsured driver fails to stop at a red light, hits your car and causes you to have 15,000 in damages. The at-fault underinsured driver (At-Fault's) has of Liability Coverage. Your policy contains 100,000 of Uninsured Motorist Coverage. NEW COVERAGE (IF APPLICABLE) (This coverage is also referred to as Uninsured Motorist-Added on to At-Fault Liability Limits) At-Fault's Liability Coverage Limit Your New Uninsured Motorist Coverage Limit 100,000 Total Amount of Your Damages 15,000 Payment Break Out: At-Fault's Liability Coverage = Your New Uninsured Motorist Coverage = Total Payment = Amount Not Covered = 100, ,000 The maximum available coverage in this example was 1 (At-Fault's Liability Coverage Limit + Your New Uninsured Motorist Coverage Limit). Please notice that 5,000 of the loss was not covered. TRADITIONAL COVERAGE (IF APPLICABLE) (This coverage is comparable to your current coverage. The coverage is also referred to as Uninsured Motorist Coverage-Reduced by At-Fault Liability Limits) At-Fault's Liability Coverage Limit Your Traditional Uninsured Motorist Coverage Limit 100,000 Total Amount of Your Damages 15,000 Payment Break Out: At-Fault's Liability Coverage = Your Available Traditional Uninsured Motorist Coverage = Total Payment = Amount Not Covered = 100,000 5,000 (b) The amount shown here is determined by subtracting the At-Fault's Liability Coverage Limit from Your Traditional Uninsured Motorist Coverage Limit. The total available Traditional Uninsured Motorist Coverage you have in this example is. (b) Please notice that 5,000 of the loss was not covered. ACORD 1 GA (009/0) Page 5 of 5