Child Safety Seat Plan�kc c
U C)
)-230-6,
Child Safety Seat Plan 2021 22.
As per the order of the City of Northampton 319-19-4
April 26, 2021
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
safety restraint required.
- Bards,
effrey r Miller
Owner
Cosmic Cab Coml2any 160 Main St. #8. Northampton MA 01060
(413) 230-6119
Office ! Agent: 46a0028 DECLARATIONS - MASSACHUSETTS
Tax I.D. No.: BUSINESS AUTO COVERAGE FORM
Policy Number: 1020093350 02 MM 00 97 09 98 A R B E L L A
ITEM ONE- NAMED INSURED AND ADDRESS Producer Name and Address 415-0028
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 01/18/2021 TO 0111812C22 12.01 A.M, Standard Time at the Named
Reason for Declaration. VC ENDORSEMENT Insured's Address slated above
(Named Insured's Business: INDIVIDUAL DIRECT BILL
Effective Date. D412012021
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 orrly'hoee covarages where a charge is shown in" premium column below Each of these coverages will apply only to those *AuIW shown
as mvered'Autos' for a particular coverage by the entry of one or more of the symbus Irom the COVERED AUTOS Section of the Business Aube Coverage Form
next to the name of the coverage.
I IIltall ITV INSIIRIlNCE
COVERAGES
COVERED AUTOS
LIMIT
PREMIUM
:Entry of ono or more Ina
symbols from the COVERED
The mostwe vvB pay for ruiy fate aradent or loss
AUTOS Sector of the Business
Auto Coverage Form sha+v which
autos are covered autos
Compulsory Bodily Injury
7
20ODD Each Person
40,000 Each der
I
11,081
Personal Injury Pratecpurt
7
&DOO Each Party^
4
Ophonal Bodily Injury
7
100.000 Each Person
13,279
300,000 EachkGide
I
Property Damage
7
50,000 Each Arllde
t
10.598
(COMPULSORY LIMIT ssso0l
Auto Medrell Paymenn Insurance
Each Perim
Uninsured Motorists (COMPULSORY
7
SEE SCHEDULE Each Pernior
308
LIMITS s20,000440,000)
SEE SCHEDULE Each boride
Undennsured Motorists
7
SEE SCHEDULE each Perlior
INCL
SEE SCHEDULE Each Acadir
l
PHYSICAL DAMAGE INSURANCE
..er ..r .-..e;...,t. nh.,..r 1. 1... min,re th., dertuchhle for each Covered Auto_
Ua
Comprehenuw Coverage~
Ded ict"is
specified Peru Coverage
Deductible
Collison Coverage
Deductible
Limited Collision Coverage
Deductble
Loss of Usa•Rental Reimbursement
Towing and Labor
of • a
For each disablement
er
Forms and Endorsements attached to this Coverage Form:
26 AP 1056 01110)} CA 00 01 ((10/01) tL 00 21 (04198)
26 AP 1057 (01110) CA 23 86 (01106) MM 99 11 (10111)
26 AP 1092 Will CA 24 02 f 12193) MM 9918 (09198)
PREMIUM
FOR ENDORSEMENTS
ADDITIONAL OR
RETURN PREMIUM
'ESTIMATED TOTAL
PREMIUM
911201
26 AP 1102 (04111) CA 99 17 (07197}
i 26 AP 1109 (07116) IL 0017 (11/85)
m,arw. eapP,prsw muiw ar.,urr.. a«rK.. car,. ,.,m r. n.�r,+uen
MM 99 23 09198) 'This policy may be subjectro final audit
MM 99 54 rCV98)
trove dbf wry Aq.
MSURED COPY
OY2312021
Office IAgent: 46-0028 DECLARATIONS - MASSACHUSETTS
Tax I.D. No.: BUSINESS AUTO COVERAGE FORM
Policy Number: 1020093350 02 SCHEDULE - MM 00 97 09 98 A R B E L L A ITEM THREE- SCHEDULE OF COVERED AUTOS YOU OWN '+o„er,r„,„,„... ..
VEHICLE INFORMATION
Auto DESCRIPTION
Year. Make. h7otlN, eady Original Sae GVW GCW or
No. Vetuele IdeMir.w ri No. IVIN) Cost New Territory, Glyd Slate
001 O08DODGE GRAND CARAVAN SEEXTENDED 21.74p SeasngCapaaty waa.ax«.r.e,.ar,w.r,e
1 DOHN44HOBB162479 LEEDS
002 008 DODGE GRAND CARAVAN SE EXTENDED 21,740 MA
1DOHN44H18B184670 LEEDS
003 007 CHEVROLET SUBURBAN K1500 WAGON 4 39,665 MA
GNFK16367G155614 LEEDS
004 005 DODGE MAGNUM SXT WAGON 4 DR. 27 900 MA
D4GZ48VX5H511216 LEEDS
CLASSIFICATION MA
Auto Busmo . - Samoa Symbol Age Class
Na. Re Gommerclal Radius Mobile MsAact leas of
Grprp of Operation Equip Cale
Use
001 D7 $ 4189D LOCAL AmVDa
002 07 9 41890 LOCAL 7
003 08 9 41890 LOCAL
D04
41890 LOCAL 1
LIABILITY Compulsory Personal LIMBS i• Limits In Thousands
800y Iryury in4u7 Optional Property Damage Auto Uninsured
(f20.000rf40,000) Proteon
ao Es Bodily Injury IComPulsory Limit hledcal Materials underinsured
darn persleaeh ace. PersonSS,0011) payments Canputsory Lftls Motorists
Auto (S20,0001ta .1)00)
No. Premium Premitrn •Limit premium 'Limit Dad. Premium LimitPremum 'Umet Premium 'Limit Premium
001 1,5W 622 100 1,897 50 1514
300 20 44 20 INCL
002 1,583 622 100 t,897 50 40 40
300
1.514 20 44 20 INCL 003 1,583 622 700 1,897 50 1,514 40 40
300 20 44 20 INCL
004 i,563 622 100 1,897 50 40 40
1,514 20 44
300 20 INCL
PHYSICAL DAMAGE 40 40
Auto Q Vitus Type •• Specified PeNa
No. and Limit ComprehensMa Cddsfan LintltaO Codislpn
_ Cov Ded, Premium Dad. Premprm Ded
001 ACV -- Premium Ded Premium
002 ACV
003 ACV
004 ACV
Auto Pasarve .•• Tc Mrrg
No. AM Waiver Lose and F - Fee Coverage, T - Then Coverage, FIST- Fin and Then, CAC -
RV3L of Did. of Use Labor Combined Additional Coverage.
•• YES-DeilOmtae Waives at Dnduetibla.
rap Designates Policy Leval Additional Insured -Lessor applies,
Designates whether Actual Cash Value, Slated Amount Or Agroed
Value and, except for ACV, the knit of Liabddy,
No I "Wt far towing all Physleat damage loss Is payable to you and the loss Payee named Glow as Interests may gppear at the time of loss.
INSURED COPY
osa:lnn»
Office 1 Agent: 46.0028 DECLARATIONS - MASSACHUSETTS
Tax I.D. No.; BUSINESS AUTO COVERAGE FORM
Policy Number: 1020093350 02 SCHEDULE - MM 00 97 09 98 A R B E L L .A
ITEM THREE -SCHEDULE OF COVERED AUTOS YOU OWN ..anenwr,..... ei....•
VFHICt1= INFORMATION
DESCRIPTION
Auto
Year, Kiska. Model. Body
Original
It GVW, GCW v
Territory, City 6 State
No
Vehicle ldenhilcatlan No. (VON i
Cost New
Seating Capacty
.MnM rowr¢artaN Ei erap.r
006
2009 DODGE GRAND CARAVAN SE SPORT VAN
23,530
LEEDS
D8HN44E59R576432
MA
009
2010 DODGE GRAND CARAVAN SE SPORT VAN
23.175
LEEDS
D4RN4DEBAR207297
MA
010
2008 DODGE GRAND CARAVAN SE EXTENDED
21,740
LEEDS
DBHN44HXBR772469
MA
CLASSIFICATION
Auto
Business use - Pow -cc
Symuo
Age
Cu►s Radar a
Mobile
Inspect
Lass of
No
Retail. Canmard*
Group
I O1 Operation
Equip
Code
Use
AmeDa a
006
07
9
41890 LOCAL
!
009
07
9
41890 LOCAL
1
010
07
9
41890 LOCAL
LIABILITY LIMITS (• Umd(s)) in Thousands)
Compulsory
Bodily Injury
Personal
juryOptional
Damage
Auto
Uninsured
Motary
Undetmsured
($20,00(+Si00001
Protection
$B4O00 Es
Bodily I Nury
(Compul ory Liit
SS,000)
Medical
Payments
L
Compulsory Limits
Motornu
each pers.leach arc.
Persian000(S20.000IS40,000)
Auto
No
Premium
Pmm7un 'Umit
Premium
'4imR Dad. Premium
Limit Preir,um
'tJmlt Premium
'Lkmst Premium
006
1,583
622
100
1,897
50
1514
20
44
20
INCL
300
40
40
009
1,583
622
100
1.897
50
1,514
20
44
20
INCL
300
40
40
010
1,583
622
100
1,B97
50
1,514
20
44
20 INCL
300
40
40
PHYSICAL DAMAGE
Auto eta WN&TyPe - Specified Pedls Cornptehanskve Collision Limited Collision
No. and Limn
Cov. Dad. Premum Dad. Premium Dad. Premium Dad. Premium
006
ACV
009
ACV
010
ACV
Towng
uld A
art
Passive
Waiver
Lou
and
F - Fee Coverage, T - Theft Coverage. FaT - Fare and Theft, CAG -
No
Rest.
ATD
of Dad,
of Vale
Labor
Combined AdditiorW Coverage.
" YES -Designates Waiver of Dedtm bbla.
as Designates Policy Level Additional Irisured - Lessor applies.
iM Designates whether Actual Cash Value, Stated Amount or Agreed
Value and, except forACV, the lime of Liability.
Auto
NO.
Except lot towing all physical damage loss Is payable to you and the loss payee nomad below as Interests may appear at the time of loss
copyrigmod marorwr ar msuranca aarviaa... ca *0.. — P
INSURED COPY
041,7312021
Office 1 Agent: 46-0026 DECLARATIONS - MASSACHUSETTS '
Tax I.D. No.: BUSINESS AUTO COVERAGE FORM
Policy Number: 1020093350 02 (Continued) - MM 00 97 09 98 A R B E L L A
ITEM FOUR- SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMSrr{r o. r» •a»�•-.
LIABILITY COVERAGE - RATING BASIS COST OF HIRE
State Estsmatod Corr of Rite per each 5100 Fodor
Hire for each Ssate �e1n1nn Cost of Hhe means the total amount you
Coel of Hire fit ilab, my s Primary) incur for the him of •autos' you don't
Sod, Injury Prop Damage sod Injury prop Damage own {not Inrludog'autoa- you borrow or
rant fmm your Partners or employees or
their family mnrmersl. Coss of Hire
does red include charges for services
performed by motor nmem d property
Total premium or passerigars.
PHYSICAL DAMAGE COVERAGE
Coveregea 4md of Insurance
The meal vie vw ,.... n......,��_ Es[snated Annual Rate per each Stoo
0,....+.�...
Camptehenuve
AC1WI
wlaa..re ties m+.ru e
11 rl
ercaKada b sees ww,wr-ft are M erda.Eth
Specific causes
Value,
arrrwrropw resew hrfnd Wl.se
of Loes
Cost of
wrw...,ssn., mnw i-Sao
swu'1'raY 4ra'Yiewary fwo av ems a�,.r
Rapairs
by manyfa nwatr,n
Collision
or
weir...,
wweaaw ti,..arn mwrw ruA
Total Premium
a
ITEM SIX -SCHEDULE FOR GROSS RECEIPTS OR MILEAGE BASIS.
I IA.u—--L.--- -- — -
![:�]'G—�roz*R&-celoptz Per 3100 of Grose Receipts Premiums
17 Per mile
LIaWh Covere a Lfabihry Coverepe Auto Afed+eal Pa enta Auto Medico! Paunu,x i
'titian used as a pnmlum basis
FOR PUBLIC AUTOS Total Premiums
Mlnlmum Premiums
Gross Rece,pla means the total amount to whkh you are enlilled for Iransparting passe of whether you or any other tamer ongirese the trans p ngen, mail a mslchartdisa during the poky Period regerdler
A Amount you Pay to railroads, steamship line��es and other motorea Gem opert kWuating under then own JCC or PUC permits.
B Tatn which you Coed as ■ separate Rem and remit direcay to a govemerMal division.
C. C.O.0 Cope"bome for wet of mail or merchondna irxWMng eollections lees.
O Advertlabrg Revenue.
FOR REN TA LEASING t CQNCl I've E5 ad mileage of al revenue producing units operated during the policy pent.
RN
GloeS IUMIAte means the total amount to wdich you are enhged or the leasing or rental of •&doe during the (hose lath which you collect es A seprtrate item and remfl directly to a govemmental divglon. poky period and Includes tames except
%bteape means the total of as Yve And dead mileage developed by a3 the 'Wool you leased or tented to others during die policy period.
INSURED COPY
0443/2021
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESCRIPTION OF POLICY CHANGES
POLICY NUMBER POLICY CHANGES COMPANY
EFFECTIVE
1020093350 02 0412012021 ARBELLA PROTECTION
NAMED INSURED AUTHORIZED REPRESENTATIVE
JEFF MILLER
CHANGES
TRANSFER 2010 DODGE VIN 067 TO 2008 DODGE VIN 2469
26AP1109 07 16 Copyright, Insurance Services Office, Inc. 1933. Page 1 of 1
Era! Used vehh Its permission