The X Y Company Of

In consideration of the warranties and the premium hereinafter mentioned does insure the assured named and described herein upon the body, machinery and equipment of the automobile described herein while within the limits of the United States (exclusive of Alaska, the Hawaiian Islands and Porto Rico) and Canada, including while in building, on road, on railroad car or other conveyance, ferry or inland steamer, or coastwise steamer between ports within said limits, for the term herein specified and to an amount not exceeding the amount of insurance herein specified, against direct loss or damage caused while this policy is in force, by the perils specifically insured against.

Form No. 2 - Non-Valued Fire, Theft and Transportation

Agency at -------- Attached to and made

___________________ THE X Y COMPANY part of policy

___________________ No. --------

Rate at --------% Old policy No. --------

Amount, $---------- Premium, $--------

Does insure A. B., address --------, from --------, 19-, at noon, standard time, to --------, 19-, at noon, standard time, to an amount not exceeding


Warranties - The following are statements of facts known to and warranted by the Assured to be true, and this policy is issued by this Company relying upon the truth thereof: Business of Assured -------- [state occupation or means of support; if assured is a married woman, state husband's occupation!.

The following is the description of the automobile:

Trade Name

Factory or Motor Number

Type of Body

(1' Truck State


Motive Power

No.of Cylindars

Advertised Horse Power



Modal, year, letter or Into

The facts with respect to the purchase of the automobile described are as follows:

Purchased by the Assured

Actual Cost to Assured Including Equipments

The Automobile Described- is Fully Paid for by Km

Assured and is not Mortgaged or otherwise

Encumbered, Except as Follows:



New or Second hand

The uses to which the automobile described are and will be put, are--------.

The automobile described is usually kept in -------- [state whether private or public] garage, located, No. --------, Street --------, City --------, State.