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t-aqu I UI L <br />a <br />r(21Nst <br />Century <br />insurance <br />Named Insured and Mailing Address <br />SCOTT WELDY <br />22671 REVERE RD <br />EL TORO, CA 92630-6000 <br />E-mail: BIGBIRODOGOAOL.COM <br />Vehicle(s) and Driver(el <br />Veh Yew Mokeffilodel <br />1 61 OTHE VOLVO544 0 - <br />2 10 CADI CTS PERFORMANCE COSD <br />3 67 CHEV CAMARO <br />Veh Rated Driver <br />4 SCOTT WELDY <br />5 ROBERT WELDY <br />PERSONAL AUTO <br />POLICY DECLARATION <br />1Vehicle 10 Number <br />A61289410 <br />1G6DJ5EV2A0142094 <br />1243771-159395 <br />J1.1yZanamsad TIcN <br />45 0 <br />13 0 <br />AMEND - POLICY CHANGE <br />EFFECTIVE 07/24/19 <br />Account: <br />21ST CENTURY INSURANCE <br />Customer Service Center. <br />21st CENTURY INSURANCE <br />21ST CENTURY PLAZA <br />P.O. BOX 15510 <br />WILMINGTON, DE 19850-5510 <br />Policy No: 8377 29 50 <br />Policy Period: From 04130/19 <br />To: 10130/19 12:01 AM Standard Time <br />Ise Vehicle Discounts/Comments Xlp Mileage <br />07 NICD ADDITIONAL VEH 92630 1.000 <br />P MCD ADDITIONALVEH 92630 9 999 <br />P MCD ADDITION <br />Chargeable Accidents <br />i 92630 1 <br />Driver Discounts <br />GDDISD5 <br />GDDISD5 <br />GUVEKAGE IS PROVIDED WHERE <br />Coverage <br />A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE _ <br />Limit of Liability - Premium <br />Veh 1 Veh 2 <br />Veh 3 <br />A. Hndil� 1%ry Liability <br />$100, 000 each person <br />Includes 0. 8 per vehicle fraud fee <br />$300000 each accident <br />$ <br />98.00 <br />5 203.00 <br />$ 30.00 <br />B. Piro arty Damage Liability <br />^i o0 000 each accident <br />$ <br />27.0_0 <br />S 159.00 <br />V 27. 00 <br />C. Medical Payments <br />$5 000 each <br />9.00�^ <br />58.00 <br />$ 9.00 <br />Uninsured Motorist <br />..person <br />$100,000 each person <br />D. Bodily lniuy <br />$3o0 000 each accident <br />$ <br />21.00 <br />$ 106.00 <br />$ 21.00 <br />DAMAGE TO YOUR VEHICLE <br />Veh 1 Veh 2 Veh 3 <br />Actual Cash Value Less Deductible <br />Dad. Dad. Dad. <br />• Comprehensive _ <br />ACV_ $500 <br />J <br />$ <br />2.00 <br />$ 4:3.00 <br />-No Cove <br />F. Collision <br />T <br />$10o $!iUU <br />t <br />y <br />14.00 <br />$ 376.00Coyy- <br />Uninsured Motorist <br />D1. Prooft 11-am e _ <br />DErD WAIVE I DED WAIVE 1 $3500 MAX <br />$ <br />2..00 <br />$ 5.00 <br />$` 2.00 <br />Zi ssi Century <br />--- <br />G. Roadside Assistance <br />$75 each disablement <br />Included <br />Included <br />Included <br />Rental Per day <br />$ 2 S <br />Fl. Reimbursement_ max <br />1 $750 <br />$ <br />o.0i1 <br />19.00 <br />$ 0.00 <br />.i. Additional Equipment <br />_ <br />Inoluded $1 , 000 $1 , 000 <br />The first $1000 is aulcmallcally <br />Additional <br />Included wilh roverappe E or F. <br />Additional cpveraNc a Is optional_ _ <br />Total ; :t, o0a ,1, 000 <br />± <br />U . 00 <br />$ 0.00 <br />$ 0.00 <br />Total Premium Per Vehicle <br />$ <br />173. 00 <br />$ 967 .00 <br />$ 89.00 <br />If the installment bill plan is used, a service <br />charge may apply. <br />Total Premium <br />Endomement(sylAgreement(s) AppllcaUkc <br />TCU-1 (01119) <br />TCU511CA (05/18) <br />TCU631CA (02/12) <br />AU CWF9 1011 <br />Loss Payee (LP), Additional Insured (AI) Drivers Not Rated <br />Veh 5 LP NU VISION CU <br />THE POLLOWING FEE(S) MAY APPLY: 07l24/19 <br />LATE: $&.80 PAYMENT RETURNED (NSF): $10.00 �• . <br />CANCEL; $50.00 INSTALLMENT BILL PLAN SERVICE CHAROE:$4.00 <br />Awlimulmi Cvn rM y -q f-d) <br />WHEN ATTACHED TO THE PERSONAL AUTO POLICY. THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT <br />1 HE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. <br />Visit 21st.com to make policy changes, pay your premium, and more. Register online todayl For Customer Care rail 800-241-1188. <br />TCU41CA (12114) 21st C tury Insurance Company, P.O. Box 15510, Wilmington, DE 19886-5292 <br />1-M <br />