**SCHEDULE A**

| Item 4. Description of Hazards | Classification Code No. | Premium Bases | Rates | Premiums |
|---|---|---|---|---|
| (a) Premises—Operations | | | Coverage A | Coverage C |
| | | (a) Area (sq. ft.) | Per $100 sq. ft. | |
| | | (b) Frontage | Per Linear Foot | |
| | | (c) Remuneration | Per $100 of Remuneration | |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | |
| (b) Elevators | | No. Insured | Per Elevator | |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | |
| (c) Independent Contractors | | Cost | Per $100 of Cost | |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | |
| (d) Products (including completed operations) | | Sales | Per $1,000 of Sales | |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | |
| (e) Contracts as defined in Condition 3 | | (a) No. Insured | (a) Per Contract | |
| **AS PER SCHEDULES IN COMPANY FILES** | | (b) Cost | (b) Per $100 | |
| Minimum Premium $ | Total Advance Premiums $ | $ |

**SCHEDULE B**

| Item 4. Description of Hazards | Advance Premiums |
|---|---|
| 1. Owned Automobiles | Coverage A | Coverage B |
| Term and State in which the | Year of | Trade Name | Body Type & Model | Trunk Capacity | Tank | 1. Serial Number | 2. Motor Number | 3. Identification No. | Purposes of Use |
| Automobile will be Principally | Model | | | | | | | | |
| Garaged | | | | | | | | | |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | | | | | | |
| 2. Hired Automobiles | Premium Basis—Cost of Hire | | | | Estimated | Rates Per $100 Costs of Hire | Coverage A | Coverage B |
| Locations Where Automobiles | Type Hired | Purposes of Use | Cost of Hire | | | | | |
| will be Principally Used | | | | | | | | | |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | | | | | | |
| 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 | | | | | | | | |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | | | | | | |
| Class 2 Employees—Estimated Average Number | Location of Headquarters of Class 2 Employees | Rates Per Employee | Coverage A | Coverage B |
| **AS PER SCHEDULES IN COMPANY FILES** | | | | | | | | | |
| Total Advance Premiums $ | $ |

Form S-919-D.
100 copies

(For use with Comprehensive General and Automobile Liability Policy.)

Z 006876