**PREMIUM AND CLAIM HISTORY**

**INSURED:**  
CITY OR TOWN:

| Current Policy No. | Prior Yrs. | Accumulated Premium | Current Policy No. | Prior Yrs. | Accumulated Premium | Current Policy No. | Prior Yrs. | Accumulated Premium |
|--------------------|------------|---------------------|--------------------|------------|---------------------|--------------------|------------|---------------------|
|                    |            |                     |                    |            |                     |                    |            |                     |

**INSTRUCTIONS:** AUTO CLAIMS MUST SHOW NAME AND AGE OF DRIVER. WORKMEN'S COMPENSATION CLAIMS MUST SHOW NAME AND AGE OF EMPLOYEE. CONCISE DESCRIPTION OF CAUSE OF LOSS MUST BE GIVEN ON ALL CLAIMS.

| STATE BR. | POL. NO. | Driver/Employee Name | Age | Cause of Loss | Date of Accident | Reserve | Payment |
|-----------|----------|----------------------|------|---------------|------------------|---------|---------|
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
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| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.     |                      |      |               |                  |         |          |
| STATE BR. | OCC.