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ITEM SIX <br />Schedule For Gross Receipts Or Mileage Basis (Cont'd) <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 />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 />Page 12 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 />