IDENTIFICATION # (VIN#, SERIAL #) GVW IF PHYSICAL DAMAGE COVERAGE IS REQUESTED, COMPLETE SPACES BELOW IN DETAIL FOR EACH RESPECTIVE UNIT ABOVE:

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1 G U UC CMPY 0 edwood Way, uite 00, Petaluma, C 99-6 CMMC VC PPC C. ame of Business: ndividual Partnership Corporation. DB :. ame of Person Completing pplication: itle:. Mailing address: treet ddress City tate Zip. pplicant's business: 6. Years in Business: 7. Principal Garaging ddress: treet ddress City tate Zip 8. Phone umber: ( ) 9. coverage desired: 0. stimated financial worth: $. Gross receipts/last year: $. stimated next year: $ Contact ame for nspection: Contact Phone umber: P Y D V F M. Does applicant rent or lease equipment to others without drivers?.. Yes o. What is applicants D#?. What is the California DMV Filing #?. Does applicant operate under a Federal Filing (MC-90)?.. Yes o f Yes ; under whose filing (ttach a copy of the contract to this application if not under your own filing)? What is the MC#?. ist furthest state vehicles are operated in? 6. re there any vehicles WD or PD by the pplicant (including non-operational units) listed on the application?.. Yes o f Yes, xplain why they are not listed: 7. ist all cargo commodities carried: 8. Does applicant own cargo?... Yes o f o then who owns it? 9. Does applicant ire quipment?... Yes o f Yes, what is estimated annual cost of hire? : $ s ired uto coverage contractually required?... Yes o 0. Does applicant use sub-haulers?.... Yes o. Does applicant operate in the ports and/or require the applicable endorsements? Yes o. What is applicant s maximum radius of operation? P C D Y F P Y From o iability osses Physical Damage osses Company ame Policy o. Mo Yr Mo Yr umber mount umber mount as insurance been cancelled or refused by any company in the last years? Yes o xplain: # Driver s Full ame * ist all accidents in which you were principally at fault of Birth Driver's icense nfo tate icense umber o. Yrs. Commercial Driving o. of ccidents * ast 6 Months o. of Minor Convictions ast 6 Months DD FM. Does applicant employ drivers under age?.. Yes o. Do all drivers hold Class license?.... Yes o. umber of drivers employed for year:. re driving records checked and ordered on new drivers at or prior to employment?.... Yes o o. of Major Convictions ast 6 Months 000 (6-) U UC CMPY Page of

2 iability imits equested: iability (each accident): $ Uninsured Motorist Bodily njury (each accident): $ Medical Payments (each accident): $ Uninsured Motorist Property Damage (each accident): $ V C U. Y MD D M BDY YP DFC # (V#, #) GVW BY DU WD D P Y C D M G F PYC DMG CVG QUD, CMP PC BW D F C PCV U BV: U. D PUCD M Y CVG M (CV) C PPC DDUCB PYC DMG DU D BY MY GU CKWDG UDD D G W FWG:. his is my full authorization to release a claim loss history on the policies listed in this application to the utter nsurance Company Fax # his authorization does not authorize release of any specific records or documents in your claim files. his authorization expires upon the expiration of any coverage extended as a result of this application. his authorization is in compliance with the California nsurance Code; rticle 6.6 nsurance and Privacy Protection ct, ection and 79., and itle 0, California Code of egulations, ections 689. through 689.; and. routine inquiry may be made by utter to obtain applicable information concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided; and. Depending on the size and use, the California Department of Motor Vehicles requires that certain commercial autos carry limits of liability up to $70,000. he applicant hereby acknowledges that they are aware of such requirements and represents that the limits being applied for on this application are in compliance with the Department of Motor Vehicle egulations; and. completed this application with the guidance of my broker as defined in ection 6 of the California nsurance Code, who is indicated within this application: and. hereby apply for a policy of nsurance set forth above on the basis of statements contained herein, and that my Broker has reviewed and explained so that understand all Coverages, imitations and xclusions contained in the nsurance being applied for; and 6. he facts stated herein are true and request the company to issue the nsurance policy and any renewals there from in reliance hereon; and 7. he nsurance applied for will XCUD coverage on any covered auto while it is in the custody of or operated by drivers under years of age, unless such person is named as a driver in this application or is added by endorsement to the policy, and vehicles rented or leased to others without drivers; and 8. o insurance shall be effective until utter, or its authorized representative, receives and approves this application; and 9. his program may be available with a monthly payment option from U, and that if this option is elected there will be: a $0 BG F applied to each installment and supplemental bill as long as the annual premium balance is not paid in full, a $0 PYM F applied to any payment not postmarked or received by the due date, a $ UD PYM F if any payment is returned by your financial institution. ignature of pplicant: : C BK By my signature hereby declare that all Coverages, imitations, and xclusions contained in the nsurance being applied for have been reviewed with and explained to the applicant. ame of pplicant s Broker: icense #: treet ddress: City: tate: Zip Code: ignature of pplicant s Broker: 000 (6-) U UC CMPY Page of :

3 DM CG PCY. P D CFUY. M F U DM (MG CVG PCFD DU D CF) DM F U W CMMC U CVG FM his endorsement modifies insurance provided under the following: C ll BY CVG B. XCU he following is added when the declarations page indicates a premium for iability Coverage: his insurance does not apply to Bodily njury or Property Damage arising out of the maintenance, use, or operation of any covered auto listed in the CDU below: a. which is being operated at any time beyond the radius of operations shown in tem of the policy declarations; or b. which is being operated at any time beyond the legal boundaries of the state of California; or c. with a manufacturers rated gross vehicle weight greater than that recorded in the declarations or by subsequent endorsement; or d. when combined with another auto (motor truck and trailer), and the combined manufacturers rated gross vehicle weight is greater than that recorded in the declarations or by subsequent endorsement. CDU Covered uto o. Year Make Model adius Vehicle dentification umber (V) nformation required to complete this chedule, if not shown above, will be shown in the Declarations. ll other terms, conditions, and agreements of the policy shall remain unchanged. his endorsement forms a part of Policy o. issued to: by the U UC CMPY and is effective at :0.M. on FFCV D at the principle garaging location indicated in the policy declarations By signing below am verifying that have read, and had explained to me, the above endorsement and understand and agree that this endorsement accurately indicates the coverage that have requested and received and is properly limited as indicated. X pplicant s ignature (equired) (equired) 00 (-) U UC CMPY Page of

4 U nsurance Company CF UUD (CUDG UDUD) M UC QUM C / JC FM PCY UMB M UD he California nsurance Code requires an insurer to provide uninsured motorist coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance or use of a motor vehicle Uninsured motorists coverage insures the insured, his heirs, or legal representatives for all sums within the limits established by law, which such person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death to him from the owner or operator of an uninsured motor vehicle not owned or operated by the insured. n accordance with the California nsurance Code (ection 80.(a)), the insured (and each of them): DC BY X agrees that the Uninsured Motorist Coverage afforded in the policy is hereby rejected in its entirety. agrees that the Uninsured Motorist Coverage is to be provided at the financial responsibility limits of $,000 each person and $0,000 each accident. agrees that the Uninsured Motorist Coverage is to be provided at the higher limits of $ each person and $ each accident. agrees that the Uninsured Motorist Coverage is to be provided at the higher limits of $ combined single limit each accident. ny selection / rejection of coverage indicated on this form will be carried forward on all renewals issued by the company unless the insured advises us in writing. n the event the policy names more than one individual in the declarations, each of you must sign. You understand that PMUM CG F CVG and you agree to pay same if coverage is selected. ignature of nsured ignature of nsured 00 (7/0)

5 U nsurance Company PCYD DCU C F M UC CVG Under the errorism isk nsurance ct of 00, effective ovember 6, 00 (the ct ), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in ection 0() of the ct: he term certified act of terrorism means any act that is certified by the ecretary of the reasury, in concurrence with the ecretary of tate, and the ttorney General of the United tates to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United tates, or outside the United tates in the case of an air carrier or vessel or the premises of a United tates mission; to have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United tates or to influence the policy or affect the conduct of the United tates Government by coercion; and that causes losses of at least $,000,000. You should know that coverage for losses caused by certified acts of terrorism is partially reimbursed by the United tates under a formula established by federal law. Under this formula, the United tates pays 90% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. he premium for this coverage is shown below and does not include any charges for the portion of loss covered by the federal government under the ct. CCDC W C, YU MU C CCP JC CVG F CFD C F M. C JC F CFD M UC CVG X hereby elect to purchase certified terrorism coverage for a prospective premium of $ 0. hereby reject the purchase of certified terrorism coverage. Policyholder/pplicant s ignature Print ame Policy umber, if available 0 (9-07) U UC CMPY Page of