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W2LISELEN 1 UNY INSUKANLL <br />X* INSURED'S COPY ** <br />1st.com 1-800-211-SAVE F <br />RENEWAL DECLARATION 0 FER <br />UTOMOBILE PL OICY OECL.ARAT110M PAGE EFFECTIVE 12/1S/ <br />03 <br />WHENATTACHEOiDTHEPFRSONALAUTOPOLICY•THESEDECIADATIONSCOMPLETETHEPOULYANDREPRESENTIN THE EVENT PAYMENT IS NOT RECEIVED <br />THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF I AOILITY ACCORDING TO OUR RECORDS BY THE DUE DATE NOTED BELOW IN THE <br />11 <br />3111=Ij <br />STATEMENT OF ACCOUNT, YOUR POLICY <br />LInM. 51ANUAHU HML <br />BECOMES NULL AND VOID. <br />AP 3493189 <br />rrroM 12/15/03 In 06/15/04 <br />NANED INSURED AND ADDRESS LOSS PAYEE AND ADDRESS (SEE REVERSE SIDE) <br />EVIDENCE OF INSURANCE ** <br />PD <br />JOE R LA ROSA JR 60TCIVICSANTA CENTERNPLAZA <br />MARIE E LA ROSA SANTA ANA CA 91702 <br />9199 POINSETTIA AVE <br />FOUNTAIN VALLEY CA 92708 <br />CAR <br />YEAH <br />MAKE <br />MDU L <br />10 NUMBER <br />CUSS <br />COMMENTS SEE OVER) <br />1999 <br />1989 <br />ACCORD LX <br />TOYOTA P/U <br />016174 <br />002342 <br />01011221218 <br />03610221418 <br />0370522A318 <br />GeDO DRIVER DISCOUNT <br />GO10 DRIVER DISCOUNT <br />C000 DRIVER DISCOUNT <br />' <br />COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF <br />CAR I <br />CAR x <br />•CAR 3 <br />CM A <br />LIAOIUTY ARE SHOWN FOR THE COVERAO <br />n. DODILY PODnv <br />•1RcmD[ssn An rrn vnnnL rnann rrl <br />s j�00 nn Fnr,H PEnsCN s • 300 nnT>cH.SeemelD <br />D. PROPE RTY MAUDE <br />S 00 WCACHACCtOENT <br />C. MEDICAL PAYMENTS <br />S .000 EACH PERSON <br />D UNINSURED MOTORIST <br />S 00 .EDD EACH <br />PERSON S 300.DD3 EACH ACCIDENT <br />DAMAGE TOYOUR CAR <br />CART <br />CAR, <br />CARD <br />CA114 <br />ACRNt G4I E. <br />fAMR 1HEN5NE <br />3 5Q0 DED <br />S rj 00 RED <br />S 500 DED S <br />DED <br />a LL£ S <br />ly;S,L':!@.E <br />ECOlL13pN <br />S 500 OLD <br />S 500 DeD <br />s 500 DED <br />S LED <br />DI. UNINSURED MOTORIST .Pn <br />D_E_D WA VE <br />DDWAIVE <br />DE1,000D WAIVE <br />J ADVITURM. ECUIPMENT <br />S 1 I D D 0 TOTAL <br />S 1,000 TOTAL <br />S TOLLS <br />TOTAL <br />11RSi 51fIRK NSRMNIIGMYIIIY III%D <br />ADV CpAPREIIEIYNE OR 00u. (,l <br />S INCL <br />0 <br />S 0 INCL <br />S INCL <br />0 <br />S INCL. <br />ADDITIONAL COVEMGE IS OPTpNAL <br />S 0 ADD. <br />5 0 ADD'L <br />S 0 APRL S <br />ADD L <br />G. TIATNG A UDOR <br />$ $50 EACII DISADLE—a Automatically Inc ud d <br />It. RENTAL REIMBURSEMENT <br />MULTI -CAR DISCOUNT <br />TOTAL CAR 1. 1. 3. <br />TCE-70 01/99 <br />11/20/03 <br />PRESIDENT nATE <br />Late r.,H.— �.U.. ....acN. La'H,Coa.A.l:.AM... 9.00 <br />FOR CUSTOMER CARE CALL 1-800-443-3100 OR VISIT OUR WEB SITE AT 21st.COM <br />** Known Drivers of your Vehicles - STATEMENT OF ACCOUNT FOR POLICY 3493189 - <br />TOTAL PREMIUM ...............1 $1321.00 <br />** JOE LAROSA <br />** MARIE LAROSA <br />** CHRISTINE LAROSA <br />CHOOSE THE PAYMENT PLAN YOU PREFER: <br />PAY IN FULL $1321.00 DUE 12/15/03 <br />*2-PAY PLAN $ 665.00 DUE 12/15/03 <br />$ 664.00 DUE 02/15/04 <br />*4-PAY PLAN <br />$ 335.00 DUE 12/15/03 8 334.00 DUE 01/15/04 <br />$ 334.00 DUE OZ/15/04 $ 334.00 DUE 03/15/04 <br />Ie * INCLUDES $4 PER PAYMENT SERVICE CHARGE <br />4 <br />� Visit 21st.con to make policy changes, pay your Premium, and more! Regisfer today! <br />21st Century Insurance Company 6301 Owonsmouth Avenue Woodland Hills. California 91367 <br />^ J( ' <br />