(Due Date: June 19, 2000)
Company Name:________________________________________________________
NAIC Group and Company Number: _________________________________________
Consumer Information Telephone Number: ____________________________________
Company Contact Person: __________________________________
Company Contact Telephone Number: ________________________________________
Company Contact E-mail Address:_____________________________________________________
| Region | Auto Territory | Driver A | Driver B | Driver C | Driver D |
| BI+PD (20/40/15), 1B, 1 year | BI+PD (20/40/15), 2C-1, 1 year | BI+PD (20/40/15), 2D, 1 year | BI+PD (20/40/15), 6A, 1 year | ||
| Amarillo & Lubbock | 10 | ||||
| Amarillo & Lubbock | 14 | ||||
| Amarillo & Lubbock | 62 | ||||
| Coastal Texas | 7 | ||||
| Coastal Texas | 54 | ||||
| Coastal Texas | 55 | ||||
| Dallas Metro | 2 | ||||
| Dallas Metro | 27 | ||||
| Dallas Metro | 28 | ||||
| East Texas | 47 | ||||
| East Texas | 63 | ||||
| East Texas | 66 | ||||
| Far West & Panhandle | 5 | ||||
| Far West & Panhandle | 58 | ||||
| Far West & Panhandle | 65 | ||||
| Ft. Worth Metro | 4 | ||||
| Ft. Worth Metro | 34 | ||||
| Ft. Worth Metro | 46 | ||||
| Golden Triangle | 6 | ||||
| Golden Triangle | 21 | ||||
| Golden Triangle | 48 | ||||
| Harris County | 1 | ||||
| Harris County | 38 | ||||
| Harris County | 39 | ||||
| Harris County | 40 | ||||
| Heart of Texas | 24 | ||||
| Heart of Texas | 51 | ||||
| Heart of Texas | 52 | ||||
| Lower Valley | 12 | ||||
| Lower Valley | 56 | ||||
| Lower Valley | 57 | ||||
| Northeast Texas | 41 | ||||
| Northeast Texas | 42 | ||||
| Northeast Texas | 43 | ||||
| Northeast Texas | 44 | ||||
| Outer Dallas/Ft. Worth Metro Area | 13 | ||||
| Outer Dallas/Ft. Worth Metro Area | 31 | ||||
| Outer Dallas/Ft. Worth Metro Area | 32 | ||||
| Outer Dallas/Ft. Worth Metro Area | 45 | ||||
| Permian Basin | 59 | ||||
| Permian Basin | 60 | ||||
| Permian Basin | 61 | ||||
| San Angelo, Abilene, Wichita Falls | 11 | ||||
| San Angelo, Abilene, Wichita Falls | 16 | ||||
| San Angelo, Abilene, Wichita Falls | 20 | ||||
| South Central | 3 | ||||
| South Central | 23 | ||||
| South Central | 53 | ||||
| South Central | 64 | ||||
| Upper Coast | 22 | ||||
| Upper Coast | 37 | ||||
| Upper Coast | 49 |