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HomeMy WebLinkAboutDumont Pumping Services - 12/31/2020................................. SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:00AM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9: As:of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit, Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occ for BOH records. acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: DATE: iotDgtI 9k _ Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 r i -"Septage/FOG Haulers Application DATE: LICENSE NUMBER: BUSINESS NAME:SPa ce-s MAILADDRESS: PO %OK �PZ TOWN: QCI-tCX') STATE: trRr ZIP CODE: 047(�Co NAME OF OWNER: tx�eC2cCt1 BUSINESS TELEPHONE: 50H - A8'S--7183 CELL: S(NmG FAX: EMAIL: ad 5 ��JL� �C ALT EMAIL: FED ID/SS NO: i 333�►�t� NUMBER OF TRUCK(S): FEE PER TRUCK: i CJ© Truck Registration number: S k?J-YO�5 Circle one:Septage F Truck Registration number: 5\BaCY Circle one: age OG Truck Registration number: Circle one: Septage G Truck Registration number: Circle one: Septage FOG Truck Registration number: Circle one: Septage FOG ................................. SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:00AM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9: As:of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit, Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occ for BOH records. acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048. SIGNATURE: DATE: iotDgtI 9k _ TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 0-1333 %18 **Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. Ct\Dsers\sleite\Desktop\Scott's DocumentsWood Establishments- Temp\TAX CERTIFICATION FORM.doc - _ Department of Industrial Accidents = = Office of Investigations - —_ 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Tpyt cry pyt-,n,rq me -c(2 -CI\ cj\z. Address: ® Qllojc �Q� City/State/Zip:' Phone #: Are you employer? Check the appropriate box: Business Type (required): 1. am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ H Ith Care nsurance 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. ireq.] 12. they SCfcrlr� *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am air employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:S�t1tA t1 S�CtQ��DMe,&Scn. C,�r-, Insurer's Address: LAu,0\ -T0,C�l%f1 f;Z6 - C -0.9V City/State/Zip:3nt,kA_c_-l(1y 1\ej TA ` Policy # or Self -ins. Lie. # L.,-,) c— oAch Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under tire pains and penalties of perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town offrciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone FOG Customers, Mansfield, MA Business Name Address 1 Hangar 12 265 Fruit St. Mansfield, MA 2 Mooyah Burger 321 School St. Unit #140 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY -INFORMATION PAGE INSURER: MAIN STREET AMERICA ASSURANCE COMPANY 4601 TOUCHTON ROAD EAST SUITE 3400 JACKSONVILLE, FL 32245-6000 ITEM 1. NAMED INSURED AND MAILING ADDRESS: ALEC RICH (SEE NAMED INSURED ENDT) Po Box 292 NORTON NIA 02766-0292 LEGAL ENTITY: INDIVIDUAL POLICY NO: WCO2972T RENEWAL OF: WCO2972T NCCI Company No: 27103 Account No: CACO2972T AGENCY NAME AND ADDRESS: TA'Y'LOR INSURANCE AGENCY 448 TURNPIKE STREET SOUTH EASTON, MA 02375 AGENCYPHONENO.: (508)230-2244 AGENCY NO.: 201040 OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Location Schedule) ITEM2. POLICYPERIOD: From: 03-07-2019 To: 03-07-2020 Effective 12:01 A.M. Standard Time,at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 100,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: all states except: ND, OH, WA, WY and states designated in ITEM 3A of the information page. D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule Is subject to verification and change by audit. Please see Classification Schedule. Total Estimated Minimum Premium: $ 316 Audit Period: ANNUAL Date: 01-27-2019 Annual Premium: $ 1,192 Countersigned by WC 40 0p 01 A Copyright 1987 National Council on Compensation Insurance MAIN STREET AMERICA. Policy Number ASSURANCE COMPANY WCO2972T EXTENSION OF INFORMATION PAGE WORKERS COMPENSATION CLASSIFICATION SCHEDULE State of: MASSACHUSETTS Named Insured ALEC RICH Agent Name TAYLOR INSURANCE AGENCY Effective Date: 03-07-2019 12:01 A.M., Standard Time Agent No. 201040 Classification of Operation Code hb. Annual Remuneration -Remuneration Total Estimated Per $100of Estimated Annual Premium 0001-01ALEC RICH DBA DUMONT PUMPING & PUMP GRUMP FEIN # 04-3339518 PO BOX 528 TAUNTON MA 02780-0528 CLERICAL OFFICE EMPLOYEES HOC 8810 $ 15,000 .07 $ 11.00 CESSPOOL CLEANING - 9402 $ 25,000 3.92 $ 980.00 SPECIALIST CONTRACTORS - & DRIVERS TOTAL CLASS PREMIUM $ 991.00 RATE DEV SUBJECT To EXP MOD 9037 $ -99.00 TOTAL SUBJECT PREMIUM $ 892.00 TOTAL MODIFIED PREMIUM $ 892.00 STANDARD TOTAL $ 892.00 EXPENSE CONSTANT 0900 $ 250,00 FOREIGN TERRORISM .03 9740 $ 12.00 TOTAL ESTIMATED PREMIUM $ 1,154.00 MACHWC (SURCHARGE) 1.0383 0987 $ 38.00 FINAL TOTAL $ 1,192.00 POLICY TOTAL ESTIMATED ANNUAL PREMIUM $ 1,192.00 PsFJ`IE Policy Number iMMIN M102972T STREP.*r AMERICA COMMON POLICY DECLARATIONS RENEWAL OF: GROUP M102972T NGM INSURANCE COMPANY 4609 TOUCHTON ROAD EAST, SUITE 3400, JACKSONVILLE, FL 322456000 Item 1. Named Insured and Mailing Address Agent Name and Address ALEC RICH DBA DUMONT PUMPING TAYLOR INSURANCE AGENCY (SEE NAMED INSURED ENDT) PO BOX 292. 448 TURNPIKE STREET NORTON MA 02766-0292 SOUTH EASTON, MA 02375 Agent Phone No. (508)230-2244 Agent No. 2.01040 Item 2. Policy Period From: 02-08-2019 To: 02-08-2020 at 12:01 A.M., Standard Time at your mailing address shown above. Item 3. Business Description: SEPTIC TANK CLEANING Form of Business: INDIVIDUAL Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment. Coverage Part(s) Premium Commercial Property Coverage Part NOT COVERED Commercial General Liability Coverage Part NOT COVERED Crime and Fidelity Coverage Part NOT COVERED Commercial Inland Marine Coverage Part NOT COVERED Commercial Auto (Business or Truckers) Coverage Part $ 4,998.00 Commercial Garage Coverage Part NOT COVERED Total Policy Premium $ 4, 998.00 Item 5. Forms and Endorsements Form(s) and Endors"errlent(s) made a part of this policy at time of issue: See Schedule of Fomes and Endorsements Countersigned: Date: M Authorized Representative THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE NUMBERED POLICY. CODEC (07/01)_, INSURED COPY 7"1 i E MAIN S`i'tu E'1, AMERICA GROUP Policy Number: M1 02972T Renewal of: M102972T DECLARATIONS — MASSACHUSETTS BUSINESS AUTO COVERAGE FORM NGM INSURANCE COMPANY 4601 TOUCHTON ROAD EAST, SUITE 3400, JACKSONVILLE, FL 32246-6000 ITEM ONE Named Insured and Mailin Address Agent Name and Address ALEC RICH DBA DUMONT PUMPING TAYLOR INSURANCE AGENCY (SEE NAMED INSURED ENDT) PO BOX 292 448 TURNPIKE STREET NORTON MA 02766-0292 SOUTH EASTON, MA 02375 Agent Phone No. (508) 230--2244 Agent No. 201040 POLICY PERIOD From: 02-08-2019 To: 02-08-202.0 a, g, f01 A.M. Standard Time at your mailing address shown above. FORM OF BUSINESS: [u] CORPORATION LIMITED LIABILITY COMPANY INDIVIDUAL PARTNERSHIP a OTHER BUSINESS DESCRIPTION SEPTIC TANK CLEANING IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL OF THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. ENDORSEMENTS ATTACHED TO THIS POLICY: IL 00 21 - Broad Form Nuclear Exclusion (Not Applicable irt;Neyv York) SEE SCHEDULE OF FORMS AND ENDORSEMENTS COUNTERSIGNED BY (Date) (Authorized Representative) AU-DEO-(1)MA 09/02 Includes copyrighted material of Insurance Services Office, Page 1 of 5 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS This policy provides only those coverages where a charge is shown in the premium column below, Each of these coverages will apply only to those "autos" shown as covered "autos." "Autos" are shown as covered autos" for a particular coverage by the entry of one or more of the symbols from the COVERED AUTOS Section of the Business Auto Coverage Form next to the name of the coverage, LIABILITY INSURANCE COVERED "AUTOS" COVERED AUTOS each person i Optional Bodily Injury (Entry of one or more each person COVERAGES of the symbols from the COVERED AUTOS LIMIT PREMIUM Property Damage Section shows which $ 500,000 each accident (Compulsory Limit autos are covered each accident $5,000 autos) $ 250, 000 each person $ 198 Compulsory Bodily 7 1$1,000,000 $20,000 each person $ 2, a64 Injury 7 $40,000 each accident $ 606 Personal Injury Protection 7 $8,000 each person $ 90 LIABILITY INSURANCE COVERED "AUTOS" each person Optional Bodily Injury each person (Compuisory,Umit - 7 each accident S 16 Property Damage $ 500,000 each accident (Compulsory Limit each accident $5,000 7 $ 250, 000 each person $ 198 Liability 7 1$1,000,000 each accident $ 2, a64 Medical Payments each person Uninsured Motorists (Compuisory,Umit - 7 $ 250,000 each person S 16 $20,000/$40,000)", $ 500,000 each accident Underinsured Motorists 7 $ 250, 000 each person $ 198 S 5oo,0oo each accident Table continued on next page AU-DEG-(2)MA 09/02 Includes copyrighted material of Insurance Services Office, with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY Page 2 of 5 'This Policy may be subject to final audit. AU-DEC-(3)MA 09102 Includes copyrighted material of Insurance Services Office, Page 3 of 5 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY COVERED AUTOS (Entry of one or more of the symbols from COVERAGES the COVERED AUTOS LIMIT PREMIUM Section shows which autos are covered autos) Physical Damage Actual Cash Value Or Cost Of Comprehensive Repair, Whichever Is Less Minus Coverage 7 $ SEE SCHEDoz,E Ded. For $ 300 Each Covered Auto. Physical Damage Actual Cash Value Or Cost Of Specified Causes of Repair. Whichever Is Less Minus Loss Coverage $ Ded. For Each Covered Auto. Physical Damage Actual Cash Value Or Cost Of Collision Coverage Repair. Whichever Is Less Minus $SEE SCHEDULE Ded. For 779 Each Covered Auto, Physical Damage Actual Cash Value Or Cost Of Limited Collision Repair. Whichever Is Less Minus Coverage $ Ded. For Each Covered Auto. Physical Damage $ For Each Towing and Labor Disablement Of A Private Passenger "Auto". Premium for Endorsements $ 200 *Esftated Total Premium _ Is 4, 998 'This Policy may be subject to final audit. AU-DEC-(3)MA 09102 Includes copyrighted material of Insurance Services Office, Page 3 of 5 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS. LIABILITY COVERAGE —RATING BASIS, COST OF HIRE Cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or employees or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. PHYSICAL DAMAGE COVERAGE ESTIMATED COST OF RATE PER EACH FACTOR (if Liability STATE HIRE FOR EACH $100 COST OF Coverage Is primary) PREMIUM STATE HIRE COST OF HIRE ACTUAL CASH VALUE OR COST OF BI REPAIRS. MINUS Ded. PD COMPREHENSIVE TOTAL PREMIUM NOT APPLICABLE Cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or employees or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. PHYSICAL DAMAGE COVERAGE AU-DEC(4)-MA 09/02 Includes copyrighted material of Insurance Services Office, Page 4 of 5 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY LIMIT OF INSURANCE ESTIMATED RATE PER EACH COVERAGES THE MOST WE WILL PAY ANNUAL COST $100 ANNUAL PREMIUM DEDUCTIBLE OF HIRE COST OF HIRE ACTUAL CASH VALUE OR COST OF REPAIRS. MINUS Ded. COMPREHENSIVE FOR EACH COVERED AUTO. BUT NO DEDUCTIBLE, APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING. ACTUAL CASH VALUE OR COST OF SPECIFIED REPAIRS. MINUS $25 Ded. FOR CAUSES OF LOSS EACH COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM. ACTUAL CASH VALUE OR COST OF COLLISION REPAIRS. MINUS Ded, FOR EACH COVERED AUTO. TOTAL PREMIUM AU-DEC(4)-MA 09/02 Includes copyrighted material of Insurance Services Office, Page 4 of 5 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY ITEM FIVE SCHEDULE FOR NONOWNERSHIP LIABILITY. Named Insured's Business Rating Basis Number PREMIUM Other than a Social Service Agency Number of Employees Number of Partners Social Service Agency Number of Employees Number of Volunteers TOTAL PREMIUMS MINIMUM PREMIUMS TOTAL PREMIUM NOT APPLICABLE i i EM S1X SCHEDULE FOR GROSS RECEIPTS OR MILEAGE BASIS -- LIABILITY COVERAGE -- PUBLIC AUTO OR LEASING RENTAL CONCERNS. ESTIMATEDRATES YEARLY 0 Per $loo of Gross Receipts El Per Mile ED GROSS RECEIPTS Per $100 of Gross Receipts F-1 MILEAGE LIABILITY AUTO MEDICAL COVERAGE PAYMENTS PREMIUMS LIABILITY COVERAGE AUTO MEDICAL PAYMENTS TOTAL PREMIUMS MINIMUM PREMIUMS When used as a premium basis: FOR PUBLIC AUTOS Gross Receipts means the total amount to which you are entitled for transporting passengers, mail or merchandise during the policy period regardless of whether you or any other carrier originate the transportation. Gross Receipts does not include: A. Amounts you pay to railroads, steamship lines, airlines and other motor carriers operating under their own ICC or PUC permits. B. Advertising Revenue. C. Taxes which you collect as a separate item and renvt directly to a governmental division. D_ C.O.D. collections for cost of mail or merchandise including collection fees. Mileage means the total live and dead mileage of all revenue producing units operated during the policy period. FOR RENTAL OR LEASING CONCERNS Gross receipts means the total amount to which you are entitled for the leasing or rental of 'autos" during the policy period and includes taxes except those taxes which you collect as a separate item and remit directly to a governmental division. Mileage means the total live and dead mileage developed by all the "autos" you leased or rented to others during the policy period. AU-DEC(5)-MA 09102 Includes copyrighted material of Insurance Services Office, Page 5 of 5 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN AU -AUTOS SCHED-MA 04105 Includes copyrighted material of Insurance Services Office, Page 1 of 2 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY DESCRIPTION TERRITORY PURCHASED Year, Model, Trade Name, Body Type, Serial Town & State Where the Covered Auto No. Number(S), Vehicle Identification Number (VIN) Mass Plate No. Exp. Date Original Cost New Actual Cost & New (N) Used (U) Covered Auto will be principally garaged Terr/Zone Code !AAI 2,010, 126IICP G(, AfJM C04dENTIoCAT, Y09 DI,C CAB ty 7NPIaJOXOAiNi0Ci5'10 $ 1351805 ACV NOii'I'CN PAti, 0iti, GiA2 200"r', .'i'.'&R(diiG 5X4 "9560 SERiE5 1;3 mi4; QMN, CI -A 1:ANKER, ("'FLNALCV4"1AZG: o's'31 :x101, N24 ACV h10RTON - uv, (il i, CLASSIFICATION Except for towing all physical damage Covered Auto No. Radius of Operation (in Miles) Business Use s=service r=retail c=commercial f =farm Size GVW, GCW or Vehicle Seating Capacity Age Group Primary Rating Factor Secondary Rating Factor Code Pre-Insp Code loss is payable to you and the loss payee named below as interests may appear at the time of the loss U. Dam. L1ab. Dam. Nil!1 51 .2,,WO 9 1,00 1 401613 MA2 50 52,000 8 1.00 1 40159 AU -AUTOS SCHED-MA 04105 Includes copyrighted material of Insurance Services Office, Page 1 of 2 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED COPY COVERAGES —PREMIUMS, LIMITS AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that the limit or deductible entry in the corresponding ITEM TWO column applies instead) Compul ry Bodily Personal Liability Covered Injury Injury Auto Medical Uninsured Motorists Underinsured Auto No. $20,000 Protection Payments (Compulsory Limit $20,000e , Motorists ea. pets. $6,000 ea. pets. $40,000 as, aoc.) Property Damage $40,000 pets. ea. ace, Optional Bodily (Compulsory Limit Injury $5,000) Premium Premium `Limits Premium 'Limit Premium "Limit Premium `Limits Premium 'Limits Premium iifi i. 703 ro 1,000 1,432. 1,000 jw"i, 2.50/500 9 2401500 ".. ld42 301, -20 1, COo 1, A'32 1, 000 INCL 5 250,`500 3 .`, 250J50u 99 -7 ISpecified Causes Comprehensive Collision Limited CollisionI' Covered "Li mit of Loss Waiver of Auto No Liability Deductible Towing &Labor Cov. Ded, Pre Dad, Prem, Ded. Prem. Ded. Prem.', t•5s,k 1,000 1.47 S ;,opo $ 361 4410 1,000 153 $ 1.,060 .3 413 'Umit(s) in thousands "Designate whether ACV. Stated Amount or Agreed Value and, except for ACV. the Limit of Liability. 1F = Fire Coverage T = Theft Coverage F&T = Fire and Theft Coverage CAC = Combined Additional Coverage AU -AUTOS SCHED-MA 04105 Includes copyrighted material of Insurance Services Office, Page 2 of 2 with its permission. Copyright, Insurance Services Office, Inc. 1997 INSURED CCPV POLICY NUMBER: M102 9')2T COMMERCIAL AUTOMOBILE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM Transfer Of Rights Of Recovery Against Others To Us — of SECTION IV — BUSINESS AUTO CONDITIONS is amended by adding the following: We waive any right of recovery we may have against any person or organization to or for whom we make payment and with whom you have a written contract that requires such waiver because of payments we make for damages under this Coverage Form. 64-8724 03 08 INSURED COPY