# Comprehensive Automobile Liability Insurance Coverage Schedule

**POLICY NO.:** GA 8596100  
**EFFECTIVE DATE:**  
**AGENCY NO.:**

## Automobile Liability Hazards

### Description of Hazards

#### 1. Owned Automobiles - Premium Basis - Per Automobile

- **Location in which the Automobile Will Be Principally Garaged:**
- **Year of Manufacture:**
- **Trade Name:**
- **Body Type and Model:**
- **Truck, Tank, or Bus Capacity:**
- **Gallons:**
- **Seating Capacity:**
- **Identification Number:**
- **Serial Number:**
- **Motor Number:**
- **Purposes of Use:**
- **Total Advance Premium:**
  - **Bodily Injury:**
  - **Property Damage:**

#### 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:**

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

- **Total Advance Premium:**
  - **$ BI:**
  - **$ PD:**

### Notes

When used as a premium basis:
A. "cost of hire" means the amount incurred for (a) 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 (b) pick-up, transportation or delivery service of property passengers other than such services performed by motor carriers which are subject to the same requirements of any motor carrier law or ordinance. The rate for each $100 of "cost of hire" shall be 5% of the applicable premium rate in effect, provided the insurer has issued a certificate of insurance to the named insured for Bodily Injury Liability and Property Damage Liability insurance covering the interest of the named insured on a direct primary basis as respects such automobile and submitting evidence of such insurance to the named insured.
B. "Class 1 persons" means all persons who perform their usual duties in the business of the named insured include the use of non-owned automobiles. (a) employees, including officers, of the named insured compensated for the use of such automobiles by salary, commission, terms of employment, or specific operating allowance of any sort; (b) all direct agents and 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 007023**