/ Insurance Application

Schedule of Covered Autos

Applicant Name: policy number:

SECTION A – Unit type ABBREVIATIONS & use codes

Tractors / Trucks / Trailers / Tank Trailers / Use Codes /
CABOVER. / CAB / Dump Truck / dmp / AUTO CARRIER / AUC / LIVE BOTTOM / LBT / INSULATED / INS / Primary code ( # ) /
CONVENTIONAL / CON / Single axle / sax / CHASSIS / CHA / LIVESTOCK / LST / PNEUMATIC / PNE / Service / S
HOT SHOT / HSH / TANDEM axle / tax / DUMP (BELLY) / DPB / LOW BOY / LOB / STNLESS STEEL / STS / Retail / R
SINGLE AXLE / SAX / Tank / tnk / DUMP (END) / DPE / LOGGING / LOG / MISC. TANKER / MST / Commercial / C
SPARE / SPR / light truck / lgt / FLATBED / FBD / POLE / POL / Secondary code (*)
YARD / YRD / Light 5th wheel / ltf / GOOSENECK / GSN / PUP / PUP / (for Truckers only)
Other ______ / otr / GRAIN HOPPER / GRH / REEFER / REF / Terminal àTerminal / t
GRAIN TRAILER / GRT / VAN / VAN / Intercity Delivery / i

SECTION B - physical damage coverages

Provide deductible(s) to request coverage. Indicate Stated Amount or ACV.
TRACTORS / TRUCKS / TRAILERS / OTHER / check one:
COMPREHENSIVE
(where available) / Stated Amount
Specified Perils
collision / Actual Cash Value
dumping / (where available)

SECTION C - specific unit information

H = Hired, O = Owned

# / Model Year / Make / Unit Type / Complete VIN # / License
Plate # / H orO / GVW/ GCW / Principal Garaging (city, state) / Radius / Use
# / * / Original Cost new / Current value
1
2
3
4
5
6
7
8
9
10
# / Model Year / Make / Unit Type / Complete VIN # / License
Plate # / H orO / GVW/ GCW / Principal Garaging (city, state) / Radius / Use
# / * / Original Cost new / Current value
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Indicate Loss Payees (LP) and/or Additional Insureds (AI) by unit. If additional space is necessary, use the Remarks Supplement.

Unit Number(s) / Check All Applicable: / Name and Address of Loss Payee and/or Additional Insured / Additional Insured’s Interest
LP AI
LP AI
LP AI
LP AI
LP AI
Extras: Describe and state the value of tarps, chains, binders, C/B’s, sidekits, satellites, telephones and/or Special Equipment attached to vehicles. Indicate the appropriate unit number. Also, include the value of extras in the unit value stated above. If additional space is required, use Remarks Supplement. / Unit # / Description / Value

INITIALED BY: APPLICANT: DATE AGENCY: DATE

LGSUP 002A 0905 (Page 1 of 2) Lincoln General Insurance Company, York, PA