# Comprehensive Automobile Liability Insurance Coverage Schedule

**POLICY NO:** GA 86-68-700  
**EFFECTIVE DATE:**  
**AGENCY NO.:**

## Automobile Liability Hazards

### Description of Hazards

1. **Owned Automobiles — Premium Basis—Per Automobile**
   - Town or City and State: 
   - Year of Model:
   - Trade Name:
   - Body Type and Model: Truck, Car, Van, or Bus
   - Seating Capacity:
   - Identification Number: Serial Number / Motor Number:
   - Purposes of Use:

2. **Hired Automobiles — Premium Basis—Cost of Hire**
   - Types Hired:
   - Locations where Automobiles Will Be Principally Used:
   - Purposes of Use:
   - Estimated Cost of Hire:
   - Rates Per $100 Cost of Hire: BI | PD

3. **Non-Owned Automobiles — Premium Basis—Class 1 Persons and Class 2 Employees**
   - Class 1 Persons—Name of Each:
   - Location of Headquarters of Persons Named Herein:

4. **Class 2 Employees—Estimated Average Number**
   - Location of Headquarters of Class 2 Employees:
   - Rates Per Employee: BI | PD

### Minimum Premiums Sections 2 and 3
- BI: $  
- PD: $  

### Total Advance Premium: $  

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**When used as a premium basis:**
A "cost of hire" means the amount incurred for the hire of automobiles, including the entire remuneration of each employee of the named insured engaged in the operation of such automobiles subject to an average weekly maximum remuneration of $100, and for all pickup, transportation, or delivery service of property or passengers, other than such services performed by motor carriers which are subject to the liability requirements of any motor carrier law or ordinance. The cost of hire shall be 5% of the applicable hired automobile rates, provided the owner of such hired automobile has purchased automobile Bod. Ins. from the named insured's Property Casualty Insurance covering the interest of the named insured on a direct primary basis as respects such automobile and submits evidence of such insurance to the named insured.

B "Class 1 persons" means the following persons, provided their usual duties in the business of the named insured include the use of non-owned automobiles (all employees), including officers, of the named insured compensated for the use of such automobiles by salary, commission, terms of employment, or specific operational control, and not direct agents or representatives of the named insured.

C "Class 2 employees" means all employees, including officers, of the named insured, not included in Class 1 persons.

**Form No. S76**  
**Z 007097**