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I*orntional General >> <br />A.W. He & Health Imumnce <br />P Box 3199 • Winston Salem, NC 27102-3199 <br />THOMAS E BYSTRY <br />915 WYCLIFFE <br />IRVINE CA 92602 <br />Policy Number: <br />Named Insured: <br />Thomas E Bystry <br />Policy Period: <br />5/21/2020-5121/2021 <br />Date of Notice: <br />Policy Underwritten By: <br />2006521219 <br />03MZU020 2:34 AM <br />Integon National <br />Insurance Company <br />24 Hour Claim 1611porting: 1-800-468-3466 <br />For Policy Information: 1-877468-Me <br />www.MyNatGenPolicy.com <br />Your Agent: <br />Fiesta Auto Insuf tce Center Store <br />#Ca078 <br />1714 E McFadden Ave Ste P <br />Santa Ana CA 92705 <br />(714) 884-4284 <br />CA COMMERCIAL VEHICLE DECLARATIONS PAGE <br />Renewal Effective 05/21/2020 12:01 AM <br />Drivers, Employees and Household Residents <br />#1 Thomas E Bystry <br />--- Driver Status License # Lic State Date of Birth 0;ender <br />Marital Status <br />Driver Pts <br />Yrs. Licensed <br />Owner Driver XXX9358 CA 10126/1957 Male <br />Married <br />0 <br />46 <br />#2 Jennifer L Bystry <br />Driver Status License # Lic Stale Date of Birth Gender <br />Marital Status <br />Driver Pts <br />Yrs. Licensed <br />Relative 2/6/1978 Fent61e <br />Married <br />0 <br />26 <br />Excluded <br />Insured Vehicle(s) and Schedule of Coverages <br />#1 2011 HOND ELEMENT LX VIN: <br />Usage: Personal Use Radius: 0 <br />5J6YH1H32BL003266- <br />Only <br />BD3335 <br />Garaging Location: 92602 <br />Policy Coverage Level ScheduledAuto <br />Coverages Provided <br />Bodily Injury / Property Damage - <br />Combined Single Limit <br />Medical Payments <br />Uninsured / Underinsured MoURW <br />Combined Single Limit <br />Discounts Applied <br />Policy Level <br />Limits/Deductibles <br />$1,000,000 Combined Single Limit <br />$10,000 Each Person / Each Accident <br />$100,000 Combined Single Limit <br />Premium <br />$798.00 <br />$63.00 <br />$112.00 <br />Total for this Vehicle $973.00 <br />Combined Vehicle Premium <br />Acquisition Expense <br />CA Vehicle Assessment and Fraud Fee <br />10039CA (06012014) Business Experience <br />$973.00 <br />$20.00 <br />$1.76 <br />Total 12 Month Policy Premium $994.76 <br />Ride Management DMsinn <br />REvIEWED & APPROVED BY: <br />'� Risk Management Analyst <br />