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ITEM FOUR <br />Schedule Of Hired Or Borrowed Covered Auto Coverage And Premiums (Cont'd) <br />Rental Period Rating Basis For Mobile Or Farm Equipment <br />Estimated Number Of <br />Days Equipment Will <br />Be Rented <br />Premium <br />Town and State <br />Where The Job Site <br />Mobile <br />Farm <br />Coverage <br />Is Located <br />Equipment <br />Equipment <br />Mobile Equipment <br />Farm Equipment <br />Liability — Primary <br />$ <br />$ <br />Coverage <br />Liability — Excess <br />$ <br />$ <br />Coverage <br />Personal Injury <br />$ <br />$ <br />Protection <br />Medical Expense <br />$ <br />$ <br />Benefits <br />(Virginia Only) <br />Income Loss <br />$ <br />$ <br />Benefits <br />(Virginia Only) <br />Auto Medical <br />$ <br />$ <br />Payments <br />Total Premiums <br />$ <br />$ <br />Page 10 of 13 © Insurance Services Office, Inc., 2009 <br />oR,N F RiskMougementDMslcrn <br />a� REVIEWED & APPROVED BY. <br />`® tq {iceva�o <br />Risk Management Specialist <br />CA DS 03 03 10 0 <br />