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ITEM FIVE <br />Schedule For Non -ownership Liability <br />Named Insured's <br />Business <br />Rating Basis <br />Number <br />Premium <br />Other Than Garage Service <br />Number Of Employees <br />$ <br />Operations And Other Than <br />Social Service Agencies <br />Number Of Partners <br />(Active and Inactive) <br />$ <br />Garage Service Operations <br />Number Of Employees Whose <br />$ <br />Principal Duty Involves <br />The Operation Of Autos <br />Number Of Partners <br />$ <br />Active and Inactive <br />Social Service Agencies <br />Number Of Employees <br />$ <br />Number Of Volunteers Who <br />$ <br />Regularly Use Autos <br />To Transport Clients <br />Number Of Partners <br />$ <br />(Active and Inactive) <br />Total Premium <br />$ <br />ITEM SIX <br />Schedule For Gross Receipts Or Mileage Basis <br />Address Of Business Headquarters Location: <br />Type Of Risk (Check one): Public Autos <br />Leasing Or Rental Concerns <br />Rating Basis (Check one): Gross Receipts (Per $100) <br />Mileage (Per Mile) <br />Estimated Yearly Gross Receipts Or Mileage): <br />Premiums <br />Liability <br />$ <br />Personal Injury Protection <br />$ <br />Added Personal Injury Protection <br />$ <br />Property Protection Insurance (Michigan Only) <br />$ <br />Auto Medical Payments <br />$ <br />Medical Expense And Income Loss Benefits (Virginia Only) <br />$ <br />Comprehensive <br />$ <br />Specified Causes Of Loss <br />$ <br />Collision <br />$ <br />Towing And Labor <br />$ <br />CA DS 03 03 10 © Insurance Services Office, Inc., 2009 <br />oR,N F RiskMougementDMslcrn <br />a� REVIEWED & APPROVED BY. <br />tq t�ceva�o <br />— J Risk Management Specialist <br />Page 11 of 13 0 <br />