Insurance DeclarationsOffice/ Agent: 46-0028 DECLARATIONS - MASSACHUSETTS
Tax I.D. No.: BUSINESS AUTO COVERAGE FORM
Policy Number: 1D20093350 01 MM 00 97 09 98 A R B E L L A
Pn OTECTION IN5URAN=C �aMNgT
ITEM ONE- NAMED INSURED AND ADDRESS Producer Name and Address 46-0028
JEFF MILLER LIGHTHOUSE INS AGCY LTD
DBA COSMIC CAB 540 GALLIVAN BLVD
160 MAIN ST STE 8 SUITE 211
NORTHAMPTON, MA 01060 DORCHESTER, MA 02124
POLICY PERIOD: Policy Covers FROM 0111812020 TO 0111812021 12:01 A.M. Standard Time at the Named
Reason for Declaration: VC ENDORSEMENT Insured's Address stated above
Named Insured's Business: INDIVIDUAL DIRECT BILL
_Effective Date: 06/25/2020 _
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL TERMS OF THIS
POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
ITEM TWO - SCHEDULE OF COVERAGES AND COVERED AUTOS
This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "Autos" shown
as covered "Autos" for a particular coverage by the entry of one or more of the symbols from the COVERED AUTOS Section of the Business Auto Coverage Form
next to the name of the coverage.
LIABILITY INSURANCE
COVERAGES COVERED AUTOS LIMIT PREMIUM
symbols from the COVERED (Entry of one or more the The most we will PeY anyone one accident or loss
AUTOS Section of the Business
Auto Coverage Form show which
autos are covered autos.
Compulsory Bodily Injury 7 20,000 Each Person 10,044
40,000 Each Accident
Personal Injury Protection 7 Each Person 4-086
Optional Bodily Injury 7 100,000 Each Person 9,858
300 000 Each Accident
Property Damage 000 Each Accident
(COMPULSORY LIMIT $5,000) 7 50,9,402
Auto Medical Payments Insurance Each Person
Uninsured
LIMITS $20,0001$40,000) 7 Each Person 276
SEE SCHEDULE Each Accident
Underinsured Motorists 7 SEE SCHEDULE Each Person
SEE SCHEDULE Each Accident INCL
PHYSICAL DAMAGE INSURANCE
Actual Cash Value or cost of repair, whichever is less, minus the deductible for each Covered Auto.
Comprehensive Coverage Deductible
Specified Perils Coverage Deductible
Collision Coverage Deductible
Limited Collision Coverage
Loss of Use -Rental Reimbursement
Towing and Labor
Forms and Endorsements attached to this Coverage Form:
26 AP 1056 (01110)
CA 00 01 (10/01)
IL 00 21 (04/98)
26 AP 1057 (0Ill 0)
CA 23 86 (01/06)
MM 99 11 (10111)
26 AP 1092 (01/10)
CA 24 02 (12/93)
MM 9918 (09198)
26 AP 1102 (04/11)
CA 99 17 (07/97)
MM 99 23 (09/98)
26 AP 1109 (07/16)
IL 00 17 (11/85)
MM 99 54 (09/98)
Includes copyrighted material of Insurance Services Once with its permission.
Countersigned by:
For each disablement
PREMIUM
FOR ENDORSEMENTS
ADDITIONAL OR
3,181
*ESTIMATED TOTAL I �j
PREMIUM J 114
This policy may be subject to final audit.
Augwrized F3eprnsentetive
071151an7n
Office/ Agent: 46-0028 DECLARATIONS - MASSACHUSETTS
Tax I.D. No.: BUSINESS AUTO COVERAGE FORM
Policy Number. 1020093350 01 SCHEDULE - MM 00 97 09 98 A R B E L L A'
ITEM THREE- SCHEDULE OF COVERED AUTOS YOU OWN PROTECTION INSYRAN. C : : Nr..NY
VEHICLE INFORMATION
nFSraiprinm
Auto
No.
Year, Make, Model, Body
Vehicle Identification No. (VIN)
Original
Cost New
Size GVW, GCW or
Seating Capacity
Territory, City & State
where the covered auto vAQ be garaged
002
2008 DODGE GRAND CARrAN SE EXTENDED
21,740
LEEDS
1D8HN44H088162479 c
MA
003
2008 DODGE GRAND CARAVAN SE EXTENDED
21,740
LEEDS
1D8HN44H18B184670 ,/
MA
004
2001 CHEVROLET SUBU BAN K1500 WAGON 4
36,260
LEEDS
3GNFK16T91G181969
MA
005
2007 CHEVROLET SUBURB N K1500 WAGON 4
39,665
LEEDS
3GNFK16367G155614
MA
GLAUSIrIGATION
Auto
Business use - Service
Symbol
Age
Class
Radius
Mobile
Inspect
Loss of
No.
Retail, Commercial
Group
of Operation
Equip
Code
Use
Amt/Da s
002
07
9
41890
LOCAL
003
07
9
41890
LOCAL
004
08
9
41890
LOCAL
1
005
08
9
41890
LOCAL
1
LIABILITY
LIMITS (' Limit(s)in
Thousands)
Com ulso
p ry
Bodily Injury
Personal
Injury
Optional
Property Damage
Auto
Uninsured
Motorists
Underinsured
(S20,000I$40,000)
Protection
;8,000 Ea
Bodily Injury
(Compulsory Limit
$5,000)
Medical
Payments
Compulsory Limits
Motorists
each pers./each acc.
Person
($20,0001$40,000)
Auto
No.
Premium
I Premium
"Limit Premium
'Limit Ded. Premium
Limit Premium
'Limit Premium
'Limit Premium
002
1,674
681
100
1,643
50
1567
20
46
20
INCL
300
40
40
003
1,674
681
100
1,643
50
1,567
20
46
20
INCL
300
40
40
004
1,674
681
100
1,643
50
1,567
20
46
20
INCL
300
40
40
,
20
46
20
INCL
3001
1
1
1
40
40
PHYSICAL DAMAGE
Auto
@ Value Type
•' Specified Perils
Comprehensive
Collision
limited Collision
No.
and Limit
Cov. Ded. Premium
Ded. Premium
Ded. Premium
Ded. Premium
002
ACV
003
ACV
004
ACV
005 iACV
"'
Towing
Na
Passive
ATD
Waiver
Loss
and
F - Fire Coverage, T - Theft Coverage. F&T -Fire and Theft, CAC -
Rest.
of Ded.
of Use
Labor
Combined Additional Coverage.
YES -Designates Waiver of Deductible.
## Designates Policy Level Additional Insured - Lessor applies.
Designates whether Actual Cash Value, Stated Amount or Agreed
Value and, except for ACV, the limit of Liability.
Auto I Except for towing all physical damage loss is
No. p g p Ys 9 payable to you and the loss payee named below as interests may appear at the time of loss.
Of
with
0711512020
Office/ Agent: 46-0028 DECLARATIONS - MASSACHUSETTS
Tax I.D.'No.: BUSINESS AUTO COVERAGE FORM
Policy Number: 1020093350 01 SCHEDULE - MM 00 97 09 98
ITEM THREE- SCHEDULE OF COVERED AUTOS YOU OWN
VEHICLE INFORMATION
ARBE LLA'
PNOTECTWN i NSupAN [ M/•N
DESCRIPTION
Auto
Year, Make, Model, Body
Original
Size GVW, GCW or
Territory, City & State
No.
Vehicle Identificaflon No. (VIN)
Cost New
Seating Capacity
whore u,e covered auto W be garaged
006
2005 DODGE MAGNUM SST WAGON 4 DR.
27,900
LEEDS
2D4GZ48VX5H511216 %
MA
007
2008 CHRYSLER PT CRUISER TOURING SPORT
18,930
LEEDS
3A8FY581328T198416I1
MA
CLASSIFICATION
Auto
Business use - Service
Symbol
Age
Class
Radius
Mobile
Inspect
Loss of
No.
Retail, Commercial
Group
of Operation
Equip
Code
Use
Aml/Da s
006
08
9
41890
LOCAL
1
007
06
9
41890
LOCAL
1
1
LIABILITY LIMITS
(' Limit(s) in Thousands)
Compulsory
Personal
Injury
Property Damage
Auto
Uninsured
Bodily Injury
Protection
Protection
Optional
(Compulsory Limit
Medical
Motorists
Underinsured
($20,000440,000)
Bodily Injury
;5,sor
Payments
Compulsory Limits
Motorists
each pers./each acc.
Person
($20,0001$40,000)
Auto
No.
Premium
Premium
'Limit Premium
'Limit Ded. Premium
Limit Premium
'Limit Premium
'Limit Premium
006
1,674
681
100
1,643
50
1567
20
46
20
INCL
300
40
40
007
1,674
681
100
1,643
50
1,567
20
46
20
INCL
300
40
40
PHYSICAL
DAMAGE
Auto
@ Value Type
"' Specked Perils
Comprehensive
Collision
Limited Collision
No.
and Limit
Cov. Ded. Premium
Ded. Premium
Ded, Premium
Ded. Premium
006
ACV
007
ACV
Auto
...
Towing
No.
Passive
ATD
Waiver
Loss
and
F - Fire Coverage, T - Theft Coverage, FST - Fire and Theft, CAC -
Rest.
of Ded.
of Use
Labor
Combined Additional Coverage.
"•' YES -Designates Waiver of Deductible.
## Designates Policy Level Additional Insured - Lessor applies.
@ Designates whether Actual Cash Value, Stated Amount or Agreed
Value and, except for ACV, the limit of Liability.
Auto
No.p
Except for towing all physical damage loss Is payable to
9 p Ys g p ya you and the loss payee named below as Interests may appear at the time of foss.
Includes copyrighted material of Insurance Services Office with its permission.
0711 5r2020
Office 1 Agent: 46-0028 DECLARATIONS - MASSACHUSETTS 1
Tax I.D. No.: BUSINESS AUTO COVERAGE FORM A R B E L L A
Policy Number: 1020093350 01 (Continued) - MM 00 97 09 98
PROTECTION IH5U R•N-[ rrtnNN.
ITEM FOUR- SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS.
LIABILITY COVERAGE - RATING BASIS, COST OF HIRE
State Estimated Cost of Rate per each $100 Factor Premium
Hire for each State I Cost of Hire I (if liab, cov, is Primary)
Sod. Injury Prop. Damage
Total Premium
Bod. Injury Prop.Damagel
Cost of Hire means the total amount you
incur for the hire of "autos" you don't
own (not Including "autos" you borrow or
rent from your partners or employees or
their family members). Cost of Hire
does not include charges for services
performed by motor carriers of property
or passengers.
PHYSICAL
DAMAGE
COVERAGE
Coverages
Limit of Insurance
Estimated Annual
Rate per each $100
Premium
The most we will pay, Deductible
Cost of Hire
Annual Cost of Hire
Comprehensive
Actual
wrrirhever is less. minus $
deductible for each covered auto, but no deductible
Cash
Value,
applies to loss caused by fire or lighWnq
whiaraver is less, minus $25.00
Specific causes
Loss
Cost of
deductible for each covered auto for loss caused
of
Repairs
or
by misadel or vandalism
Whlotwv is less, minus $
Collision
deductible for each covered auto
Total Premium
ITEM FIVE- SCHEDULE FOR NON -OWNERSHIP LIABILITY
Named Insured's Business
Rating Basis
Number
Premium
Bodily Injury Prop Damage
Other than a Social Services Agency
No. of Employees
No. of Partners
Social Services Agency
No. of Employees
No. of Volunteers
Total Premium
ITEM SIX -SCHEDULE FOR GROSS RECEIPTS OR MILEAGE BASIS -
LIABILITY COVERAGE -PUBLIC AUTO LEASING RENTAL CONCERNS
Estimated Yearly
❑ Gross Receipts
Mileage
Rates
Premiums
Per $100 of Gross Receipts
Per mile
Llabili Coverage
Auto Medical Payments
Total Premiums
When used as a premium basis:
FOR PUBLIC AUTOS
Minimum Premiums
Gross Receipts means the total amount to which you are entitled for transporting passengers, mail or merchandise during the policy period regardless
of whether you or any other carrier originate the transportation Gross receipts does not include:
A. Amount you pay to railroads, steamship I nes, aid nes and other motor carriers operating under their own ICC or PUC permits.
B. Taxes which you collect as a separate item and remit directly to a governmental division.
C. C.O.D. collections for cost of mail or merchandise including collections fees.
D. Advertising Revenue.
Mileage means the total live and dead mileage of all revenue producing units operated during the policy period.
FOR RENTAL OR LEASING CONCERNS
Gross receipts means the total amount to which you are entitled for the leasing or rental of "autos" during the policy period and includes taxes except
those taxes which you collect as a separate item and remit directly to a governmental division.
Mileage means the total of all live and dead mileage developed by all the "autos" you leased or rented to others during the policy period.
Driver Information:
Driver Name
Date of Birth License Number
copyrighted material of Insurance Services
07/1512020
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESCRIPTION OF POLICY CHANGES
POLICY NUMBER
POLICY CHANGES
COMPANY
EFFECTIVE
1020093350 01
06/25/2020
ARBELLA PROTECTION
NAMED INSURED
AUTHORIZED REPRESENTATIVE
JEFF MILLER
CHANGES
ADD 2008 CHRY #8416
26AP1109 0716 Copyright, Insurance Services Office, Inc., 1983, Page 1 of 1
Used with its permission
?30 L'\�
Child Safety Seat Plan 2020/21.
As per the order of the City of Northampton 319-19-4
July,18 2020
Cosmic Cab will provide a front or rear facing Child Safety Seat or Booster Seat upon the request of any
customer. The customer will need to schedule at least 1 hour in advance to ensure the availability of the
Best Bards,
�Je rey D. Miller
Owner
safety restraint required.
Cosmic Cab ComQany 160 Main St. #8 Northam ton MA 01060
(413) 230-6119