WHEREAS, The employee whose signature appears below agrees to furnish his own
automobile to perform his duties hereunder and shall keep it maintained and repaired in good
driving condition; and

WHEREAS, for the employee’s benefit, the employee shall maintain insurance on the
automobile in at least the following amounts: Bodily injury liability, __________(1)________
Dollars ($_______________) for each person injured, ____________(2)______________
Dollars ($________________) for each occurrence; property damage liability _____(3)_____
Dollars ($________________) for each accident; _________(4)____________ Dollars
($___________) deductible comprehensive coverage, _____________________(5)
_______________ Dollars ($_________________); ________(6)__________ Dollars
($________________) deductible collision coverage at fair market value; and
WHEREAS, a certification of the employee’s insurance showing those coverage’s will be
filed by the employee with the company; and

WHEREAS, all of the requirements of this section shall be complied with at the
employee’s cost.

NOW THEREFORE, In consideration of the above, the company shall pay the employee
_____________(7)__________ Dollars ($_______________) per week for the use of his
automobile during the period from ___________(8)___________, _____(9)_____, to ________
(10)__________, ______(11)______. Those payments shall be charged to the employee’s
account as an automobile allowance. The payments shall be made weekly, but neither the
payments nor this agreement shall make the company the owner, bail or lessee of
said automobile, nor shall the company be responsible for any damage to the automobile.

___________(12)________________
Employer

___________(13)________________
Employee