AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL)

National Casualty Company Home Office: Madison, Wisconsin Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL) COVERAGE APPLIED FOR IS RESTRICTED READ THE STATEMENT OF COVERAGE UNDERSTANDING ON PAGE 5 OF THIS APPLICATION Name of Applicant: Street Address: Agent Name: Agency Name: Address: P.O. Mailing Address Garaging Location: Agent No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant PARTIALLY COMPLETED APPLICATIONS ARE UNACCEPTABLE. ALL QUESTIONS MUST BE ANSWERED. IF A QUESTION IS NOT APPLICABLE, INDICATE NOT APPLICABLE. DESCRIPTION OF OPERATIONS 1. Applicant is: Individual Partnership Corporation Other: 2. Number of years experience as a commercial truck driver: 3. Under whose authority do you operate? Name Address Phone Number Contact Person Provide a complete copy of the current lease agreement. CA-APP-8 (6-12) Page 1 of 6

4. List below all drivers, owners/officers, partners currently employed as of the proposed effective date. Driver s Name D/C* of Birth Driver s License No. Class State of License No. of Years Driving Similar Vehicle Length of Employment List Past Three Years of Accidents and Traffic Violations *Designation Code: O Owner/Officer, P Partner, E Employee 5. Are any regulatory filings required?... Yes No If yes, provide type of filing and exact name authority is written under: 6. Previous non-trucking insurance carrier and loss experience Past three years (attach prior loss reports): Policy Period Prior Insurance Carrier Loss Details From To 7. Has insurance for this type of coverage been canceled or declined or has renewal been refused (not applicable in Missouri)?... Yes No If so, provide full details: LIMIT AND COVERAGE INFORMATION 8. Liability: Combined Single Limits: $ Split Limit: B.I. Per Person: $ B.I. Per Accident: $ Property Damage: $ Liability Deductible: $1,000 Over $1,000 $ Submit to company financials may be required. 9. Uninsured Motorist: Rejected Limits Accepted 10. Underinsured Motorist: Rejected Limits Accepted (Complete appropriate UM/UIM Selection/Rejection Form for Questions 9. and 10.) 11. Optional no-fault state: PIP rejected?... Yes No 12. Mandatory no-fault state: PIP basic limits accepted?... Yes No (Complete appropriate Personal Injury Protection Selection/Rejection Form for Questions 11. and 12.) 13. Medical Payments: Rejected Limits accepted: CA-APP-8 (6-12) Page 2 of 6

14. Are any other entities to be added as additional insureds?... Yes No If yes, list: NAME ADDRESS INTEREST/RELATIONSHIP VEHICLE SCHEDULE (Attach copies of the vehicle registration for all vehicles and explain if registration name is different from applicant s name.) Vehicle No.: Year: V.I.N.: Make/model/type of vehicle: ACV ST AMT: $ Value of perm. attached equip.: $ Mfg. seating capacity: Radius: Farthest city: City, state, zip where garaged: License state: License plate no.: GVW/GCW: Class.: Deductibles COMP SCOL COLL Commercial Retail Service Leased Vehicle?... Yes No Loss payee/additional insured/lessor: If limousine, name of coach builder: Length: Vehicle No.: Year: V.I.N.: Make/model/type of vehicle: ACV ST AMT: $ Value of perm. attached equip.: $ Mfg. seating capacity: Radius: Farthest city: City, state, zip where garaged: License state: License plate no.: GVW/GCW: Class.: Deductibles COMP SCOL COLL Commercial Retail Service Leased Vehicle?... Yes No Loss payee/additional insured/lessor: If limousine, name of coach builder: Length: CA-APP-8 (6-12) Page 3 of 6

Vehicle No.: Year: V.I.N.: Make/model/type of vehicle: ACV ST AMT: $ Value of perm. attached equip.: $ Mfg. seating capacity: Radius: Farthest city: City, state, zip where garaged: License state: License plate no.: GVW/GCW: Class.: Deductibles COMP SCOL COLL Commercial Retail Service Leased Vehicle?... Yes No Loss payee/additional insured/lessor: If limousine, name of coach builder: Length: Vehicle No.: Year: V.I.N.: Make/model/type of vehicle: ACV ST AMT: $ Value of perm. attached equip.: $ Mfg. seating capacity: Radius: Farthest city: City, state, zip where garaged: License state: License plate no.: GVW/GCW: Class.: Deductibles COMP SCOL COLL Commercial Retail Service Leased Vehicle?... Yes No Loss payee/additional insured/lessor: If limousine, name of coach builder: Length: Vehicle No.: Year: V.I.N.: Make/model/type of vehicle: ACV ST AMT: $ Value of perm. attached equip.: $ Mfg. seating capacity: Radius: Farthest city: City, state, zip where garaged: License state: License plate no.: GVW/GCW: Class.: Deductibles COMP SCOL COLL Commercial Retail Service Leased Vehicle?... Yes No Loss payee/additional insured/lessor: If limousine, name of coach builder: Length: CA-APP-8 (6-12) Page 4 of 6

STATEMENT OF COVERAGE UNDERSTANDING NOTE: In applying for non-trucking use insurance, you understand that there is no coverage when you are operating under the authority of others or when leased to others. If you have any questions about the coverage you are applying for, please discuss them with your insurance agent. This application does not bind YOU or US to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued. A COMPLETED COPY OF YOUR LEASE AGREEMENT MUST ACCOMPANY THE APPLICATION. California Notice And Disclosure: Please note a policy fee of $150 applies to NEW business policies only. This policy fee is fully earned at policy inception FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FRAUD WARNING (APPLICABLE IN FLORIDA): Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. APPLICABLE IN HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN MAINE): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. CA-APP-8 (6-12) Page 5 of 6

NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleadin g information is guilty of a felony. NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. APPLICANT S NAME AND TITLE: APPLICANT S SIGNATURE: (Must be signed by an active owner, partner or executive officer) PRODUCER S SIGNATURE: DATE: DATE: AGENT NAME: AGENT LICENSE NUMBER: (Applicable to Florida Agents Only) IMPORTANT NOTICE As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. CA-APP-8 (6-12) Page 6 of 6

Pennsylvania IMPORTANT NOTICE Insurance companies operating in the Commonwealth of Pennsylvania are required by law tomake available for purchase the following benefits for you, your spouse or other relatives orminors in your custody or in the custody of your relatives, residing in your household,occupants of your motor vehicle or persons struck by your motor vehicle: (1) Medical benefits, up to at least $100,000. (1.1) Extraordinary medical benefits, from $100,000 to $1,100,000 which may be offered inincrements of $100,000. (2) Income loss benefits, up to at least $2,500 per month up to a maximum benefit of atleast $50,000. (3) Accidental death benefits, up to at least $25,000. (4) Funeral benefits, $2,500. (5) As an alternative to paragraphs (1), (2), (3) and (4), a combination benefit, up to at least$177,500 of benefits in the aggregate or benefits payable up to three years from thedate of the accident, whichever occurs first, subject to a limit on accidental deathbenefit of up to $25,000 and a limit on funeral benefit of $2,500, provided that nothingcontained in this subsection shall be construed to limit, reduce, modify or change theprovisions of section 1715(d) (relating to availability of adequate limits). (6) Uninsured, underinsured and bodily injury liability coverage up to at least $100,000because of injury to one person in any one accident and up to at least $300,000because of injury to two or more persons in any one accident or, at the option of theinsurer, up to at least $300,000 in a single limit for these coverages, except for policiesissued under the Assigned Risk Plan. Also, at least $5,000 for damage to property ofothers in any one accident. Additionally, insurers may offer higher benefit levels than those enumerated above as well asadditional benefits. However, an insured may elect to purchase lower benefit levels than thoseenumerated above. Your signature on this notice or your payment of any renewal premium evidences your actualknowledge and understanding of the availability of these benefits and limits as well as thebenefits and limits you have selected. If you have any questions or you do not understand all of the various options available to you, contact your agent or company. If you do not understand any of the provisions contained in this notice, contact your agent orcompany before you sign. SIGNATURE DATE

A. Medical Expense Benefit: Coverage to reimburse you for reasonable and necessary medical treatment and services incurred. B. Income Loss Benefit: Coverage to replace a portion of lost income and reimburse you for expenses in securing replacement services. C. Accidental Death Benefit: A death benefit paid in the event of the death of an injured person due to a covered auto accident. D. Funeral Benefit: Coverage to pay for direct funeral, burial and other related expenses incurred as a result of the death of an insured person due to a covered accident. According to Pa. C. S. Title 75 Chapter 17, you are required to purchase a minimum of $5,000, Medical Expenses. All other options listed below (including a higher limit of Medical Payments) are choices for you to make. Indicate your choice of options shown below for each coverage. Then date and sign this form and return to your Agent. BENEFIT LEVEL OPTIONS: (Include your choice by marking the box with a X for each coverage or for your choice of Combination Benefits option). A. MEDICAL EXPENSES: Per Person, Per Accident with minimum and maximum benefits as shown: $5,000 $ $10,000 $ $25,000 $ $50,000 $ $100,000 $ B. INCOME LOSS: Per Month, Per Person, Per Accident with minimum and maximum benefits as shown: None-Rejected $1,000/$ 5,000 $ $1,000/$15,000 $ $1,500/$25,000 $ $2,500/$50,000 $ C. ACCIDENTAL DEATH: Per Person, Per Accident with minimum and maximum benefits as shown: None-Rejected $ 5,000 $ $10,000 $ $25,000 $ D. FUNERAL EXPENSE: Per Person, Per Accident with minimum and maximum benefits as shown: None-Rejected $ 1,500 $ $2,500 $ OR COMBINATION BENEFITS: This coverage is a combination of benefits. Do not complete this section if you have elected to purchase any of the above options. $ 50,000 ($2,500 Funeral and $10,000 Accidental Death Benefits) $ $100,000 ($2,500 Funeral and $10,000 Accidental Death Benefits) $ $177,500 ($2,500 Funeral and $25,000 Accidental Death Benefits) $ $277,500 ($2,500 Funeral and $25,000 Accidental Death Benefits) $ AND EXTRAORDINARY MEDICAL BENEFIT (EMB): Extraordinary Medical Benefits Coverage is an optional coverage. It pays the medical expenses of eligible persons for accidents covered under your policy. Payments under this coverage begin only when covered medical expenses exceed $100,000 and capped at the lifetime limit of $1,000,000. The first $100,000 of medical expenses are not covered by this coverage. If you select the Extraordinary Medical Benefits Coverage and your First Party Medical Benefits limit is less than $100,000, you will be responsible for the difference. Do not include; $100,000 $300,000 $500,000 $1,000,000. Signature of First Named Insured

Named Insured: Policy Number: Underinsured motorist coverage provides protection for damages incurred as a result of an accident with an underinsured motor vehicle. Pennsylvania law requires Underinsured Motorist protection be offered, but the purchase is optional. There is an additional premium for this coverage. Coverage can be rejected by the signing of a separate form. If you have decided to purchase Underinsured Motorist (UIM) protection, the law allows you to select a limit no less than $35,000 or no more than the Combined Bodily Injury and Property Damage Coverage Limit this policy presently provides. We have provided several options for the Underinsured Motorist (UIM) limit. Please check the box indicating the limit for either a combined coverage limit or split limit with or without stacked limits. Stacking means you can claim a total of the amounts of underinsured motorist coverage assigned to each vehicle in your policy. If you reject stacked limits, each vehicle insured under the policy will have its own limits of uninsured motorist coverage. There is an additional premium for this coverage. Stacked coverage can be rejected by the signing of a separate form. Please indicate your choice(s) below: Underinsured Motorist (UIM) Non-stacked Stacked Combined Limits Split Limits Combined Limits Split Limits $ 35,000 $ 15,000/$ 30,000 $ 35,000 $ 15,000/$ 30,000 $ 50,000 $ 50,000/$ 100,000 $ 50,000 $ 50,000/$ 100,000 $100,000 $100,000/$ 300,000 $100,000 $100,000/$ 300,000 $250,000 $250,000/$ 500,000 $250,000 $250,000/$ 500,000 $500,000 $500,000/$ 1,000,000 $500,000 $500,000/$ 1,000,000 $750,000 $750,000 $ 1,000,000 $ 1,000,000 By signing and dating this limits offer, I am selecting the above limits for Underinsured Motorists (UIM). I act on full authority of all insureds under this policy. I realize these limits will remain unchanged on future policies unless I notify the insurance company in writing. First Named Insured Position Signature of First Named Insured By signing this waiver, I am rejecting underinsured motorist coverage under this policy, for myself and all relatives residing in my household. Underinsured coverage protects me and relatives living in my household for losses and damages suffered if injury is caused by the negligence of a driver who does not have enough insurance to pay for all losses and damages. I knowingly and voluntarily reject this coverage. First Named Insured Position Signature of First Named Insured

By signing this waiver, I am rejecting stacked limits of underinsured motorist coverage under the policy for myself and members of my household under which the limits of coverage available would be the sum of limits for each motor vehicle insured under the policy. Instead, the limits of coverage that I am purchasing shall be reduced to the limits stated on the policy. I knowingly and voluntarily reject the stacked limits of coverage. I understand that my premiums will be reduced if I reject this coverage. First Named Insured Position Signature of First Named Insured

Named Insured: Policy Number: Uninsured motorist coverage provides protection for damages incurred as a result of an accident with an uninsured motor vehicle. Pennsylvania law requires Uninsured Motorist protection be offered, but the purchase is optional. There is an additional premium for this coverage. Coverage can be rejected by the signing of a separate form. If you have decided to purchase Uninsured Motorist (UM) protection, the law allows you to select a limit no less than $35,000 or no more than the Combined Bodily Injury and Property Damage Coverage Limit this policy presently provides. We have provided several options for the Uninsured Motorist (UM) limit. Please check the box indicating the limit for either a combined coverage limit or split limit with or without stacked limits. Stacking means you can claim a total of the amounts of uninsured motorist coverage assigned to each vehicle in your policy. If you reject stacked limits, each vehicle insured under the policy will have its own limits of uninsured motorist coverage. There is an additional premium for this coverage. Stacked coverage can be rejected by the signing of a separate form. Please indicate your choice(s) below: Non-stacked Uninsured Motorist (UM) Stacked Combined Limits Split Limits Combined Limits Split Limits $ 35,000 $ 15,000/$ 30,000 $ 35,000 $ 15,000/$ 30,000 $ 50,000 $ 50,000/$ 100,000 $ 50,000 $ 50,000/$ 100,000 $100,000 $100,000/$ 300,000 $100,000 $100,000/$ 300,000 $250,000 $250,000/$ 500,000 $250,000 $250,000/$ 500,000 $500,000 $500,000/$ 1,000,000 $500,000 $500,000/$ 1,000,000 $750,000 $750,000 $ 1,000,000 $ 1,000,000 By signing and dating this limits offer, I am selecting the above limits for Uninsured Motorists (UM). I act on full authority of all insureds under this policy. I realize these limits will remain unchanged on future policies unless I notify the insurance company in writing. First Named Insured Position Signature of First Named Insured By signing this waiver, I am rejecting uninsured motorist coverage under this policy, for myself and all relatives residing in my household. Uninsured coverage protects me and relatives living in my household for losses and damages suffered if injury is caused by the negligence of a driver who does not have any insurance to pay for losses and damages. I knowingly and voluntarily reject this coverage. First Named Insured Position Signature of First Named Insured

Signature of First Named Insured By signing this waiver, I am rejecting stacked limits of uninsured motorist under the policy for myself and members of my household under which the limits of coverage available would be the sum of limits for each motor vehicle insured under the policy. Instead, the limits of coverage that I am purchasing shall be reduced to the limits stated in the policy. I knowingly and voluntarily reject the stacked limits of coverage. I understand that my premiums will be reduced if I reject this coverage. First Named Insured Position Signature of First Named Insured

Signature of First Named Insured I am rejecting underinsured motorist coverage under this rental or lease agreement, and any policy of insurance or self-insurance issued under this agreement, for myself and all other passengers of this vehicle. Underinsured coverage protects me and other passengers in this vehicle for losses and damages suffered if injury is caused by the negligence of a driver who does not have enough insurance to pay for all losses and damages. Print Name of Person Renting or Leasing Signature of First Named Insured

Signature of Person Renting or Leasing I am rejecting uninsured motorist coverage under this rental or lease agreement, and any policy of insurance or self-insurance issued under this agreement, for myself and all other passengers of this vehicle. Uninsured coverage protects me and other passengers in the vehicle for losses and damages suffered if injury is caused by the negligence of a driver who does not have any insurance to pay for losses and damages. Printed Name of Person Renting or Leasing Signature of Person Renting or Leasing