<p> Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 ♦ Fax: 888-265-7353 [email protected]</p><p>Experience transporting COMMERCIAL DRIVER EMPLOYMENT wheelchair bound and/or HISTORY (Public Auto) special needs passengers Insured Name: % Policy No.: Driving Vehicle Types Listed: 1-7 pass. %</p><p>8-16 pass. % Driver Name: Date of 16 or more % Birth: License Explain All Other: Number: Date of Employment: From (MO/YR): To Total Years Experience: (MO/YR): Experience listed should be for the same type of Radius of Use: 0–100 Miles 101–300 equipment you will be driving on this policy. The Miles 301–500 Commercial License obtained date should be the date of Miles Over 500 license for the same type of equipment. Miles Including Current Employer, list in order of most recent employer first. MUST HAVE TWO FULL YEARS Employer: EXPERIENCE. Phone: </p><p>Address: Employer: Amount of Experience: Taxi/Livery % Phone: Limousine/Charter % Address: All Other % Amount of Experience: Taxi/Livery % Experience transporting Limousine/Charter % wheelchair bound and/or All Other % special needs passengers Experience transporting % wheelchair bound and/or Driving Vehicle Types Listed: 1-7 pass. % special needs passengers 8-16 pass. % 16 or more % % Explain All Other: Driving Vehicle Types Listed: 1-7 pass. % Date of Employment: From (MO/YR): To 8-16 pass. % (MO/YR): 16 or more % Radius of Use: 0–100 Miles 101–300 Explain All Other: Miles 301–500 Date of Employment: From (MO/YR): To Miles Over 500 (MO/YR): Miles Radius of Use: 0–100 Miles 101–300 Miles 301–500 Have you had any accidents in the last three years? Miles Over 500 Yes No Miles Have you had any tickets in the last three years? Yes No Employer: Phone: If yes, please list dates and violations: Address: The undersigned applicant represents that the Amount of Experience: Taxi/Livery % information provided herein is true and correct. I further Limousine/Charter % understand that by applying for insurance, I authorize All Other %</p><p>ADM-1037 (10-16) Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 ♦ Fax: 888-265-7353 [email protected]</p><p>Scottsdale Insurance Company to verify the information provided above.</p><p>Signature of the Named Insured or Driver Date</p><p>ADM-1037 (10-16)</p>