Item 5: Principal Place of Garaging

Item 5: Principal Place of Garaging Item 6: Secured Lender/Lessor— Additional Insured, if Rented Aut( AUTO I CAMBRIDGE 11 AUTO AERATOR INFORMATION Operator Marne Date of Birth License Uc, Number slaw Clean m Three CIC Mod Rabng OW First licensed Ow !loop sees 0-100, Mos“ 0 Om. Lem LM Od op yir 0 °memo Status .0ccoscoo P.Pnrc. E•Excli.dol. MAIM., Auto Motorcycle VI V2 V3 I I 0 0 10/20/94 N P 00 07/02/07 N 0 Identification Numbers of Endorsements Forming a Part of This Policy: MPV-0016-5 1110 CIC-2238 0514 M-0099-5 0911 CIC-2197 0513 CIC-2212 1113 Additional Information: MERIT RATING PLAN The Merit Rating Plan premium adjustment for each auto is based on the driving records of the operators listed on your policy. Premn adjustments can result from incident-free driving, or from a Merit Rating Board report of an at-fault accident or traffic law violation during five year period immediately preceding the policy effective date. The Merit Rating Board code and class of each operator are used assigning the operators to the autos in the manner described in the rating manual. For SDP Statement send request to [email protected] or call 800-922-8276 x11101 Check carefully that all operators of your auto(s) are shown. Your failure to list a household member or any individual who customan operates your auto may have very serious consequences. NOTICE: You must notify us of changes that have occurred prior to the renewal of this policy and during the policy period. It is a crime knowingly provide false or fraudulent information for the purpose of defrauding an insurance company. If you or someone else on yol behalf has knowingly given us false, deceptive, misleading or incomplete information and if such false, deceptive, misleading or incomple information increases our risk of loss, we may refuse to pay claims under any or all of the Optional Insurance Pads and we may cancel yo policy. Such information includes the description and the place of garaging of the vehicle(s) to be insured, the names of all househo members and customary operators required to be listed and the answers given above for all listed operators. We may also limit a payments under Part 3 and Part 4. Check to make certain that you have correctly listed all operators and the completeness of their previol driving records. The Merit Rating Board may verify the accuracy of the previous driving records of enlisted operators. We will not pay for a collision or limited collision loss for an accident which occurs while your auto is being operated by a household memb who is not listed as an operator on your policy. Payment is withheld when the household member, if listed, would require the payment additional premium on your policy because the household member would be classified as an inexperienced operator or would requi payment of additional premium on your policy under the Merit Rating Plan. Auio Rating Grass Pram Town Slat Gums Rik Tpo A; HT CLAP Annual Milano Rtsk Level Years Lie Gm, MR Graz CC Loy Rea MA Lc, Grow Como sym Carl Lisa PiRI, alrc 1 1101 600 11U1 I U p.AA 5 B 99 13 l si n 1s6 Di 2 _iime•me. A it _ . a / USE At et41 : el Icr 'err ioRarhi tot estrT Rate Type I 72441°M Coun signed by Authorized Agent EFTA01136398