Laserfiche WebLink
ACSC 10/24/2018 12:04:23 PM PAGE 5/007 Fax Server <br />Interinsurance Exchange of the Automobile Club <br />Automobile Insurance Policy Coverages and Limits <br />Modified Renewal Declarations (continued) <br />2 GAMBOALEVY, LYSA FEMALE MARRIED 1978 <br />3 LEVY. NATHAN -IXCLUDID" MALE SINGLE 2015 <br />4 LEVY, NOAH MALE SINGLE 2017 <br />5 LEVY, ADAM J - EXCLUDED" MALE SINGLE 2010 <br />" IMPORTANT: NO COVERAGE 18 PROVIDED BY THIS POLICY WHILE ANY VEHICLE 19 BEING OPERATED BY AN EXCLUDED DRIVER. PLEASE <br />READ THE"EXCLUSION OR DESIGNATED PERSON ENDORSEMENT' AOREEMENIT PREVIOUSLY RROVID[D TO YOU. IEndorsarnam No. 2184 <br />DRIVING RECORD <br />DRIVER NUMBER OF TRAFFIC CONVICTICNB RATED <br />NUMBER PRINCIPALLY DRIVER STATUS VEHICLE <br />AT-FAULTACCIDENTe Mauna aaaxviaI Ma.inx I•nnv ni.".u"innie NUMBER <br />■NDORSWI EMS AND CERTIFICATES <br />NUMBER T TITLE <br />2011 MEMBERS AUTOMOBILE POLICY— POLICY NUMBER CHANGE <br />2052 LOSS PAYABLE - NOTICE TO LIENHOLDER <br />2161 ADDL INSURED NOTICE • DRIVER <br />2184 EXCLU&ION OF DESIGNATED PERSON <br />2296 SELECTION OF UMIUIM COVERAGE ENDORSEMENT <br />2387 AMENDATORY ENDORSEMENT <br />PRIMARY <br />PRIMARY <br />EXCLUDED <br />PRIMARY <br />EXCLUDED <br />SPICIALSQUIPMENT"" <br />I SOUND NQUIPMENT"" <br />VEH. <br />NO. <br />CAMPER! <br />VAN CONV. <br />rnREa <br />2.WAY TELE. <br />RADIO FHCNE <br />Maio <br />a 1211 <br />4 <br />7 <br />8 <br />'Cover"a le Indloated by a"YES" In the appropriate equipment <br />odumn. Owerape limitations appry unless camragewee <br />purchased spedfledlyfor cxtaln equipment, <br />ANY PHYSICAL DAMAGE LOSS MAY BE MADE PAYABLE TOYOUANDANY INTEREST LISTEDIROW: <br />LONG BEACH CITY EFOU <br />PO BOX 1787 <br />LONG BEACH CA 80601 <br />PERSON 048IONATID TO RECEIVE NONPAYMENT OF PREMIUM NOTION: <br />An Ind vidwel deafgnafed by a pallcyncdd@r M recelve nolks of Lpae, termtnegad <br />expiration, nonlerawal, or oance'Iallol or Hie Panay mr nonpaym m Of Omnum <br />doss not nays any dgrRa, whaMar as an addhldnsl Inaumd or alhahVMq to any <br />OanMMa under In* Panay, Other Mon Ina right to MONW Am". <br />WN =10 Click AAA,comlmyaeeount to access your pelley Information online, pay your bill or <br />print additional proof of insurance cards <br />a,(, 4-- %`fv <br />