Page 1

INSURANCE COMPANY
6101 ANACAPRI B L V D . , LANSING, MI 4 8 9 1 7 - 3 9 9 9
D I X I E LEAVITT AGENCY
43-0080-00
MKT TERR 096

( 4 3 5 ) 586-9463

COMPETITIVE EXCAVATION INC

AUTOMOBILE POLICY DECLARATIONS

PREFERRED PROGRAM
Renewal E f f e c t i v e 0 8 - 0 2 - 2 0 1 5
POLICY NUMBER

Company
Bill
UT

47-895-282-01

Company Use

PO BOX 39
HURRICANE

19020 ( 1 0 - 8 0 )
Issued 06-17-2015

84737-0039

57-02-AZ-1208

POLICY TERM
12:01 a.m.
12:01 a.m.
to
08-02-2015
08-02-2016

I n c o n s i d e r a t i o n o f payment o f t h e premium shown b e l o w , t h i s p o l i c y i s renewed. P l e a s e a t t a c h t h i s

D e c l a r a t i o n s and a t t a c h m e n t s t o your p o l i c y . I f you have any q u e s t i o n s , p l e a s e c o n s u l t w i t h your a g e n t .
DESCRIPTION OF ITEM INSURED

TERRITORY

H i r e d Automobiles

028
Mohave C o u n t y , AZ

COVERAGES

Combined L i a b i l i t y
TERRORISM COVERAGE

LIMITS

$51.21
.26
TOTAL

79521

ITEM DETAILS: E s t i m a t e d c o s t o f h i r e - l i a b i l i t y
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5
150

$51.47

(02-11)
$ I f Any

(Subject to audit)

1010

Employers Non-Ownership L i a b .

COVERAGES

Combined L i a b i l i t y
TERRORISM COVERAGE

028
Mohave C o u n t y , AZ

LIMITS

PREMIUM

$ 1 M i l l i o n ea occ

$47.62
.24
TOTAL

A d d i t i o n a l Forms F o r T h i s I t e m :
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5

150

SPL

PREMIUM

$ 1 M i l l i o n ea occ

A d d i t i o n a l Forms F o r T h i s I t e m :

CLASS

1010

79503

(03-99)

$47.86

SPL

Page 2

19020 ( 1 0 - 8 0 )
Issued 06-17-2015

OWNERS I N S . CO.
D I X I E LEAVITT AGENCY
43-0080-00
MKT TERR 096

Company POLICY NUMBER

Bill
Company Use

COMPETITIVE EXCAVATION INC

Term 0 8 - 0 2 - 2 0 1 5 t o

1 . 1999 FORD F150

V I N : 1FKRF1726XA890482
COVERAGES

$1Million
$1Million
$1Million
$
5,000

ea
ea
ea
ea

PREMIUM

occ
p e r s / $ 1 M i l l i o n ea occ
p e r s / $ 1 M i l l i o n ea occ
pers
TOTAL

Interested Parties:

08-02-2016

028
Mohave C o u n t y , AZ
LIMITS

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
TERRORISM COVERAGE

47-895-282-01
57-02-AZ-1208

$498.04
56.94
102.97
29.01
3.43
$690.39

None

A d d i t i o n a l Forms F o r T h i s I t e m :

79332

(07-07)

79476

(07-07)

79692

(06-09)

ITEM DETAILS: L i g h t t r u c k o p e r a t e d w i t h i n a 100 m i l e r a d i u s - commercial u s e .

Gross V e h i c l e w e i g h t i s 1 0 , 0 0 0 .
I n d u s t r y T y p e : Dump Or T r a n s i t Mix Trucks - E x c a v a t i n g .
V e h i c l e Count F a c t o r A p p l i e s .
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5

150

0015001

1010

2 . 2000 FORD F150

V I N : 2FTPF17Z6YCA99502
COVERAGES

028
Mohave C o u n t y , AZ
LIMITS

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
TERRORISM COVERAGE

$1Million
$1Million
$1Million
$
5,000

ea
ea
ea
ea

PREMIUM

occ
p e r s / $ 1 M i l l i o n ea occ
p e r s / $ 1 M i l l i o n ea occ
pers
TOTAL

Interested Parties:

$649.43

None

A d d i t i o n a l Forms F o r T h i s I t e m :

79332

(07-07)

79476

(07-07)

ITEM DETAILS: L i g h t t r u c k o p e r a t e d w i t h i n a 100 m i l e r a d i u s - s e r v i c e u s e .

Gross V e h i c l e w e i g h t i s 1 0 , 0 0 0 .
I n d u s t r y Type: Contractor - Excavating.
A 5% d i s c o u n t has been a p p l i e d t o a u t o m o b i l e s used i n c o n t r a c t i n g b u s i n e s s .
V e h i c l e Count F a c t o r A p p l i e s .
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5
150

$466.73
54.09
97.82
27.56
3.23

0015001

1010

79692

(06-09)

Page 3

19020 ( 1 0 - 8 0 )
Issued 06-17-2015

INSURANCE COMPANY
6101 ANACAPRI B L V D . , LANSING, MI 4 8 9 1 7 - 3 9 9 9
D I X I E LEAVITT AGENCY
43-0080-00
MKT TERR 096

AUTOMOBILE POLICY DECLARATIONS

PREFERRED PROGRAM
Renewal E f f e c t i v e 0 8 - 0 2 - 2 0 1 5

( 4 3 5 ) 586-9463

POLICY NUMBER

COMPETITIVE EXCAVATION INC

Company Use
Company
Bill

PO BOX 39
HURRICANE

UT

47-895-282-01

84737-0039

57-02-AZ-1208

POLICY TERM
12:01 a.m.
12:01 a.m.
to
08-02-2015
08-02-2016

I n c o n s i d e r a t i o n o f payment o f t h e premium shown b e l o w , t h i s p o l i c y i s renewed. P l e a s e a t t a c h t h i s

D e c l a r a t i o n s and a t t a c h m e n t s t o your p o l i c y . I f you have any q u e s t i o n s , p l e a s e c o n s u l t w i t h your a g e n t .
DESCRIPTION OF ITEM INSURED

TERRITORY

3 . 1997 CHEV K3500

V I N : 1GBJK34J1VF025582
COVERAGES

028
Mohave C o u n t y , AZ
LIMITS

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
TERRORISM COVERAGE

$1Million
$1Million
$1Million
$
5,000

ea
ea
ea
ea

PREMIUM

occ
p e r s / $ 1 M i l l i o n ea occ
p e r s / $ 1 M i l l i o n ea occ
pers
TOTAL

Interested Parties:

CLASS

$538.32
54.09
97.82
27.56
3.59
$721.38

None

A d d i t i o n a l Forms F o r T h i s I t e m :

79332

(07-07)

79476

(07-07)

79692

(06-09)

ITEM DETAILS: L i g h t t r u c k o p e r a t e d w i t h i n a 100 m i l e r a d i u s - s e r v i c e u s e .

Gross V e h i c l e w e i g h t i s 1 0 , 0 0 0 .
I n d u s t r y Type: Contractor - Excavating.
A 5% d i s c o u n t has been a p p l i e d t o a u t o m o b i l e s used i n c o n t r a c t i n g b u s i n e s s .
V e h i c l e Count F a c t o r A p p l i e s .
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5
150

0020001

1010

4 . 2001 CHEV TAHOE K1500

V I N : 1GNEK13T71J196808
COVERAGES

028
Mohave C o u n t y , AZ
LIMITS

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
Comprehensive
Collision
TERRORISM COVERAGE

$1Million
$1Million
$1Million
$
5,000
A.C.V. A.C.V. -

PREMIUM

ea occ
ea p e r s / $ 1 M i l l i o n ea occ
ea p e r s / $ 1 M i l l i o n ea occ
ea p e r s
$ 1 , 0 0 0 ded
$ 1 , 0 0 0 ded
TOTAL

Interested Parties:

$963.02

None

A d d i t i o n a l Forms F o r T h i s I t e m :
79939 ( 0 3 - 0 5 )
89023 ( 0 7 - 0 6 )

79332
89024

(07-07)
(07-06)

79476

(07-07)

ITEM DETAILS: L i g h t t r u c k o p e r a t e d w i t h i n a 100 m i l e r a d i u s - s e r v i c e u s e .

Gross V e h i c l e w e i g h t i s 1 0 , 0 0 0 .
I n d u s t r y Type: Contractor - Excavating.
A 5% d i s c o u n t has been a p p l i e d t o a u t o m o b i l e s used i n c o n t r a c t i n g b u s i n e s s .
V e h i c l e Count F a c t o r A p p l i e s .
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5
150

$569.56
54.09
97.82
27.56
83.91
125.29
4.79

0026001

1010

79692

(06-09)

Page 4

19020 ( 1 0 - 8 0 )
Issued 06-17-2015

OWNERS I N S . CO.
D I X I E LEAVITT AGENCY
43-0080-00
MKT TERR 096

Company POLICY NUMBER

Bill
Company Use

COMPETITIVE EXCAVATION INC

Term 0 8 - 0 2 - 2 0 1 5 t o

5 . 1997 VOLV ACL64F

V I N : 4V5SCCBCH2VR51680
COVERAGES

Interested Parties:

08-02-2016

028
Mohave C o u n t y , AZ
LIMITS

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
TERRORISM COVERAGE

47-895-282-01
57-02-AZ-1208

$1Million
$1Million
$1Million
$
5,000

ea
ea
ea
ea

PREMIUM

occ
p e r s / $ 1 M i l l i o n ea occ
p e r s / $ 1 M i l l i o n ea occ
pers

$1,332.00
56.94
102.97
29.01
7.60

TOTAL

$1,528.52

(07-07)

79692

None

A d d i t i o n a l Forms F o r T h i s I t e m :

79332

(07-07)

79476

(06-09)

ITEM DETAILS: E x t r a heavy t r u c k o p e r a t e d w i t h i n a 100 m i l e r a d i u s .

Gross V e h i c l e w e i g h t i s 5 8 , 8 0 0 .
I n d u s t r y T y p e : Dump Or T r a n s i t Mix Trucks - E x c a v a t i n g .
V e h i c l e Count F a c t o r A p p l i e s .
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5

150

0070923 A 1010

6 . 2004 FORD F650SD

V I N : 3FRWF65924V684973
COVERAGES

028
Mohave C o u n t y , AZ
LIMITS

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
TERRORISM COVERAGE

Interested Parties:

$1Million
$1Million
$1Million
$
5,000

ea
ea
ea
ea

PREMIUM

occ
p e r s / $ 1 M i l l i o n ea occ
p e r s / $ 1 M i l l i o n ea occ
pers
TOTAL

$1,187.37

(07-07)

79692

None

A d d i t i o n a l Forms F o r T h i s I t e m :

79332

(07-07)

79476

ITEM DETAILS: Heavy t r u c k o p e r a t e d w i t h i n a 100 m i l e r a d i u s - commercial u s e .

Gross V e h i c l e w e i g h t i s 2 5 , 9 5 0 .
I n d u s t r y Type: Contractor - Miscellaneous.
V e h i c l e Count F a c t o r A p p l i e s .
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5

150

$992.54
56.94
102.97
29.01
5.91

0043189 A 1010

(06-09)

Page 5

19020 ( 1 0 - 8 0 )
Issued 06-17-2015

INSURANCE COMPANY
6101 ANACAPRI B L V D . , LANSING, MI 4 8 9 1 7 - 3 9 9 9
D I X I E LEAVITT AGENCY
43-0080-00
MKT TERR 096

AUTOMOBILE POLICY DECLARATIONS

PREFERRED PROGRAM
Renewal E f f e c t i v e 0 8 - 0 2 - 2 0 1 5

( 4 3 5 ) 586-9463

POLICY NUMBER

COMPETITIVE EXCAVATION INC

Company Use
Company
Bill

PO BOX 39
HURRICANE

UT

47-895-282-01

84737-0039

57-02-AZ-1208

POLICY TERM
12:01 a.m.
12:01 a.m.
to
08-02-2015
08-02-2016

I n c o n s i d e r a t i o n o f payment o f t h e premium shown b e l o w , t h i s p o l i c y i s renewed. P l e a s e a t t a c h t h i s

D e c l a r a t i o n s and a t t a c h m e n t s t o your p o l i c y . I f you have any q u e s t i o n s , p l e a s e c o n s u l t w i t h your a g e n t .
DESCRIPTION OF ITEM INSURED

TERRITORY

7 . 2015 GMC SIERRA K3500 SLT

V I N : 1GT423E89FF506573
COVERAGES

028
Mohave C o u n t y , AZ
LIMITS

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
Comprehensive
Collision
TERRORISM COVERAGE

Interested Parties:

$1Million
$1Million
$1Million
$
5,000
A.C.V. A.C.V. -

PREMIUM

ea occ
ea p e r s / $ 1 M i l l i o n ea occ
ea p e r s / $ 1 M i l l i o n ea occ
ea p e r s
$ 1 , 0 0 0 ded
$ 1 , 0 0 0 ded

$945.77
56.94
102.97
29.01
140.30
369.02
8.22

TOTAL

$1,652.23

(07-07)

79692

None

A d d i t i o n a l Forms F o r T h i s I t e m :
79939 ( 0 3 - 0 5 )
89023 ( 0 7 - 0 6 )

79332
89024

(07-07)
(07-06)

79476

(06-09)

ITEM DETAILS: Medium t r u c k o p e r a t e d w i t h i n a 100 m i l e r a d i u s - commercial u s e .

Gross V e h i c l e w e i g h t i s 1 4 , 0 0 0 .
I n d u s t r y T y p e : Dump Or T r a n s i t Mix Trucks - E x c a v a t i n g .
V e h i c l e Count F a c t o r A p p l i e s .
Rate E f f e c t i v e Date 0 4 - 2 8 - 2 0 1 5

150

0045001 A 1010

T o t a l s by c o v e r a g e

COVERAGES

Combined L i a b i l i t y
Uninsured M o t o r i s t
Underinsured M o t o r i s t
M e d i c a l Payments
Comprehensive
Collision
TERRORISM COVERAGE

CLASS

PREMIUM

$5,441.79
390.03
705.34
198.72
224.21
494.31
37.27

Page 6

19020 ( 1 0 - 8 0 )
Issued 06-17-2015

OWNERS I N S . CO.
D I X I E LEAVITT AGENCY
43-0080-00
MKT TERR 096

Company POLICY NUMBER

Bill
Company Use

COMPETITIVE EXCAVATION INC

47-895-282-01
57-02-AZ-1208

Term 0 8 - 0 2 - 2 0 1 5 t o

08-02-2016

TERM
$7,491.67
-748.49
$6,743.18

TOTAL POLICY PREMIUM

PAID I N FULL DISCOUNT
TOTAL POLICY PREMIUM I F PAID I N FULL

The P a i d I n F u l l D i s c o u n t does n o t a p p l y t o f i x e d f e e s o r s t a t u t o r y c h a r g e s .
The P a i d I n F u l l D i s c o u n t i s based on f a v o r a b l e l o s s e x p e r i e n c e f o r t h e c o l l e c t i v e group
o f p o l i c y h o l d e r s who choose t o pay t h e i r premium i n f u l l d i r e c t l y t o t h e company.

Forms T h a t Apply To A l l I t e m s :
79524 ( 0 6 - 9 2 )
79540 ( 0 3 - 9 9 )
69049 ( 1 0 - 1 1 )
79986 ( 0 8 - 0 3 )
89368 ( 0 3 - 1 1 )

79001
79580
89009

(03-99)
(04-10)
(07-06)

79419
79539
79178

(09-09)
(03-99)
(12-05)

79517
79695
89058

(01-07)
(06-09)
(04-07)

A 12% Cumulative M u l t i - P o l i c y D i s c o u n t a p p l i e s . S u p p o r t i n g p o l i c i e s a r e marked w i t h an ( X ) :

Comm Umb( ) Comm Prop/Comm L i a b ( X ) WC( ) L i f e ( ) P e r s o n a l ( ) Farm( ) .
Warning: P l e a s e r e v i e w form 79580 - Mexico Coverage L i m i t e d .
01010
00940

19020 ( 1 0 - 8 0 )
Issued 06-17-2015
INSURANCE COMPANY
6101 ANACAPRI B L V D . , LANSING, MI 4 8 9 1 7 - 3 9 9 9
D I X I E LEAVITT AGENCY
43-0080-00
MKT TERR 096

AUTOMOBILE POLICY DECLARATIONS

PREFERRED PROGRAM
Renewal E f f e c t i v e 0 8 - 0 2 - 2 0 1 5

( 4 3 5 ) 586-9463

POLICY NUMBER

COMPETITIVE EXCAVATION INC

Company Use
Company
Bill

PO BOX 39
HURRICANE

UT

47-895-282-01
57-02-AZ-1208

POLICY TERM
12:01 a.m.
12:01 a.m.
to
08-02-2015
08-02-2016

84737-0039

I n c o n s i d e r a t i o n o f payment o f t h e premium shown b e l o w , t h i s p o l i c y i s renewed. P l e a s e a t t a c h t h i s

D e c l a r a t i o n s and a t t a c h m e n t s t o your p o l i c y . I f you have any q u e s t i o n s , p l e a s e c o n s u l t w i t h your a g e n t .
000098/000099

Scheduled D r i v e r s L i s t
L i s t e d below a r e d r i v e r s c u r r e n t l y s c h e d u l e d on t h i s p o l i c y .
P l e a s e compare t h e l i s t w i t h
y o u r c u r r e n t r e c o r d s and c o n t a c t y o u r a g e n t w i t h any changes t h a t need t o be made.
We
w i l l update t h e l i s t a c c o r d i n g l y f o r t h e n e x t r e n e w a l .
Name:
Last

First

Age

Date o f B i r t h
MM-DD-CCYY

State

STEED

RULON

59

07-16-1956

UT

ZITTING

JUSTIN

23

05-18-1992

AZ

BARLOW

HAVEN

47

09-21-1967

UT

KELSCH

GREGORY

39

06-10-1976

AZ

HAMMON

NEPHI

25

08-04-1989

AZ

BARLOW

HAVEN

71

02-17-1944

AZ

BARLOW

JARED

45

03-20-1970

AZ

BARLOW

DAVID

20

03-01-1995

AZ

IMPORTANT NOTICE

EXCLUSION OF NUCLEAR, BIOLOGICAL OR CHEMICAL TERRORISM

SECTION III - DAMAGE TO YOUR AUTOMOBILE AMENDATORY

ENDORSEMENT

AMENDATORY ENDORSEMENT

AUTOMOBILE MEDICAL PAYMENTS COVERAGE

AMENDATORY ENDORSEMENT - MOBILE SPECIAL EQUIPMENT

and ROAD CONSTRUCTION, MAINTENANCE AND SPECIAL
EQUIPMENT

UNINSURED MOTORIST COVERAGE

UNDERINSURED MOTORIST COVERAGE

ARIZONA CHANGES

NEWLY ACQUIRED AUTOMOBILE COVERAGE

AMENDATORY ENDORSEMENT
SECTION II - LIABILITY COVERAGE

AMENDATORY ENDORSEMENT - SECTION III - DAMAGE TO YOUR AUTOMOBILE

WAIVER OF GLASS DEDUCTIBLE FOR REPAIR

AIR BAG REPLACEMENT COVERAGE ENDORSEMENT

EMPLOYERS' NONOWNERSHIP LIABILITY

COMBINED LIMIT OF LIABILITY

POLLUTION LIABILITY EXCLUSION

INSURING AGREEMENT

SECTION

DEFINITIONS

SECTION II - LIABILITY COVERAGE

SECTION III - DAMAGE TO YOUR AUTOMOBILE

SECTION IV - INDIVIDUAL NAMED INSURED

SECTION V - WHAT YOU MUST DO AFTER AN ACCIDENT OR LOSS

SECTION VI - GENERAL CONDITIONS