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ACSC <br />10/24/2018 12:04:23 PM PAGE 4/007 Fax Server <br />E] <br />Interinsurance Exchange of the Automobile Club <br />Automobile Insurance Policy Coverages and Limits <br />Modified Renewal Declarations <br />We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or <br />before the due date Insurance is in effect only for the vehicles, coverages, and limits of liabilityshown on this declarations page and as Bet forth <br />In the Insurance pollcy and endorsements. These declaratlans, together with the contract and the endorsements In sffaot complete your policy If <br />any change to your policy or to the Informatlon we have on flle results Ina premlum decrease during the pollcy perlod, the Interinsurance <br />Exchange reserves the right to apply any refund due to your outstanding balance. <br />LEVY, JOSEF AND (3AMBOA-LEVY, LYSA <br />4221 AVENIDA MADRID <br />CYPRESS CA 90530-3405 <br />YeMIOLee <br />POLICY EFFECTIVE DATE: <br />POLICY EXPIRATION DATE; <br />TIME) <br />08.23.18 ' 2:01 A, M <br />08.23.12 '2:01 A <br />VEH. <br />NO.YEAR <br />MAKE MODEL <br />IDENTIFICATION <br />NUMBER <br />VEHICLE <br />USE <br />GARAGE <br />ZIP CODE <br />ANNUAL•• <br />MILES <br />VERIFIED <br />MILEAGE <br />SALVAGE <br />4 <br />2011 <br />MAZD 3170JRING <br />JM18LIVF08100105S <br />PLEASURE <br />9083C <br />17,501 • 20,000 <br />VERIFIED <br />NO <br />7 <br />2007 <br />HOND CIVIC HYBRID <br />JHVFA38237600428$ <br />COMMUTE <br />9003C <br />4,5C1. 5,500 <br />VERIFIED <br />NO <br />8 <br />2000 <br />LEX5 RX 330 <br />JTJOA31 Ue50053482 <br />COMMUTE <br />9053C <br />10,001 • 12,500 <br />VERIFIED <br />NO <br />COVERAGES AND LIMITS ANNUAL PREMIUMS <br />Coverage In not In anecl unless a premlum or the word "Included" Is shown. <br />COVERAGES <br />LIMITS OF LIABILITY <br />Vehicle 4 <br />Vehicle 7 <br />Vehicle a Vehicle Vehicle <br />Lladlflty <br />Bodily Injury <br />$1,000,000 ✓9aoh person/ $1,000,000%soh occurrence <br />i $ 354 <br />$ Al <br />I $ 333 1 1 <br />Property Damage <br />81,000,000 obac7 occurrence <br />$ 226 <br />$ 598 <br />$ 228 <br />Medical <br />$ <br />$is <br />$18 <br />s18 <br />PhyslaefDamage(Actuwouhvousunosoomentlnalled,lIdodiadble) <br />Vehlcle 4 <br />Vehicle 7 <br />VaNds a VePocle VeNcle <br />Comp'e ahrelve <br />ACV <br />ACV <br />ACV <br />'Lou Deductible) <br />$500 <br />9500 <br />$500 I <br />Colllelon <br />ACV <br />No Coverage <br />ACV <br />(Leas Deductible) <br />S500 <br />No Coverage <br />$500 <br />Car Rental Expense <br />Bodily Injury- $100,000 aeon person! $300.000 each scoldait <br />UnlneLred a Underinsured Vehlcles <br />Unlreurad DeductlDlo Weyer <br />Unireured Cdlieion <br />PREMIUM DISCOUNTS <br />$50 <br />sea <br />i <br />$53 <br />$ 482 <br />No Coverage' <br />I <br />8 30E <br />850 <br />iNo Coverage: <br />$41 <br />silo <br />$97 <br />Sol <br />Included <br />:No Coverage! <br />Included <br />$ 1290 <br />Tease refer to the erolosed document entitled "Premium Discounts Appled to Your Automobl',e Polley <br />• If at any time you choose to pay lase than the full balance outstanding, <br />finance charges of up to 1.6°% per month of the balance outstanding will apply <br />as explalned In your billing statements, which are part of these deelaratlane. <br />" To sea the annual mileage for your expiring pollcy, planes refer to the <br />"Notice of Annual Mileage" page contained In your renewal package. <br />$1821 8 1002 <br />"No Coverage" Indlcates coverage not purchased. <br />Total Annual Premlum" $ 4003 <br />(Includes all appllcabie dlscounls.) <br />Lass Pollcyholder Savings Dividend $ 468 <br />Not Pramlum" 3637 <br />PROCESS DATE 08.04.18 PLEASE ATTACH TO YOUR POLICY <br />���DC /Gr� IONFr�2�i_S' �� �t=E�1�✓� �i���1�Y� <br />(son REVERSE) <br />