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SUPPLEMENTAL AUTO APPLICATION COMMERCIAL FARM AUTO LAY-UP (Risk Placement Services, Inc.)

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CA 75 02 11 04
SUPPLEMENTAL AUTO APPLICATION
COMMERCIAL FARM AUTO LAY-UP
Policy Number:
Name of Insured:
VEHICLE
NUMBER
DESCRIPTION
MONTHS
NOT USED
DAYS USED
PER YEAR
MILES
PER YEAR
I certify that the above information is true and correct. I have been advised that the Commercial Farm Auto Lay-Up credit
for the above listed vehicles is subject to adjustment based upon actual usage. The company has the option to verify
usage via audit or inspection.
Named Insured:_________________________________________________ Title:____________________________
Authorized Signature:_____________________________________________ Date:____________________________
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SUPPLEMENTAL AUTO APPLICATION COMMERCIAL FARM AUTO LAY-UP (Risk Placement Services, Inc.)

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Completed 30 July 2020

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