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<br />r~ ~~~t~~E!!'!~'YI~s~rallce <br />'''~! 21!.t.com 1-800-211-SAVE <br /> <br />. <br /> <br />PERSONAL AUTO <br />POLICY DECLARATION <br /> <br />Renewal <br />EFFECTIVE 06/15/2005 <br /> <br />, <br /> <br />Named Insured and Mailing Address <br /> <br />Joe Larosa <br /> <br />9199 Poinsettia Ave <br />Fountain Valley, CA 92708 <br /> <br /> ----- <br />Vehicle(sl and Driver(s} <br />Veh Year Model Vehicle ID Number Use Vehicle Discounts/Comments Zip Mileage <br />1 2004 PilOT lX 2HKYF18134H568983 P MCO 92708 10.000 <br />2 1989 SHORT BEO OElUXE JT4RN81P6KOO02342 W MCO 92708 9,000 <br />Veh Rated Driver Years Ticl(ets Chargeable Accidents Discounts <br /> Licensed <br /> .__._-~.~-~.~_._- - <br />1 Marie Larosa 37 0 GOO <br />2 Joe Larosa 39 0 GOO <br /> <br />Policy Period: From: 06/15/2005 <br /> <br />Policy No: 3493189 <br />To: 12/15/2005 12:01 AM Pacific Time <br /> <br />COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE <br /> <br /> Premium <br /> Coverase limit of liability Veh 1 Veh 2 <br /> ---~-~ <br />A_ Liabilit~ Bodily Injury $ 100,000 each person <br />Includes $0. 0 per vehicle fr~ud fee $ 300 000 each accident "'~'-'-'--- $ $ $ $ ---- <br />B_ Property Damaqe .------ $ 100,000 each accident ------.'"- $ $ $ $ <br />C. Medical Payments $ each person $ $ $ $ <br /> -- <br /> Uninsured Motorist $ 100,000 each person <br />D_ J~odiiy_I~u.rL ~... 100,000 each accident ---------~ _. -.i. -- $ -_.- i..___ ~~- <br /> , ----- -- <br /> DAMAGE TO YOUR VEHICLE Veh 1 Veh 2 1---- ---- <br /> Actual Cash Value Less Deductible Ded. Ded. Oed. Oed. <br /> -- --- ---.-- "'0 .._ - <br />E. Comprehensive $ 500 $ soo $ $ $ $ $ $ --- <br /> -- <br />F_ Collision $ 500 $ ~) 0 0 $ $ ~---- $ $ '-'.--- $ $--- -..- <br /> ---- <br /> Uninsured Motorist <br />01. Property Damaqe ---- OED WAIVE DED WAIV,__ ----"- -- "- $ $ $ <br />G_ Towin~ & Labor $ 50 each disablement . _ 1"~I~,,ed __ ~~JlJded ~. Included .--- ___~~Jude_L <br /> -- -_..------- <br />H_ Rental Reimbursement _L__ .._.___..P_~!.~;__ $ max 3___ $ $ $- - <br /> - -.-- ------.------ <br />J_ Additional Equipment l'lcluued $1 ,dad $1 ,000 $ $ <br /> The first $1000 is autolTwtic~Jlly Additional $ 0 $ u $ $ <br /> included with coverage E or ~ <br />-- Additional coverage is optional --- Total _$_}_, 000 $l,OOD $ __L___ ..L__ -$ . -"-- ____.._n_____ e-$ --.------ <br /> -----".- --.--....-- - ------.-- ------ -,,-- <br /> T.9~~1 Premium Per _ \I.~_~iE!~_ $ ---- _L __ --.-.- $ uU__ - <br />i"""""'".''''''' ^", ~"' "",' ^,,,,;; ,,; ---------- -.-- -'.'-"'-- .. ______ J_Q!!:!U~r!!.~.i~m_ ___.1_______.. <br />TCU-l 106/041 TCU511 CA 1051051 <br /> KOVED AS ,U , ()l(r",".i: <br /> ----- - - -- - -- --------- ---- -- -- ________n_ <br /> <br />Loss P8yce (LP). Additional Insured (AI), Evidence of Insurance (ED <br />Veh 1 EI CITY OF SANTA ANA PD <br />Veh 2 EI CITY OF SA NT A ANA PD <br /> <br />2- <br />I//'V . <br />./ll_.o;_-<-I"L (___ <br />--_ ____nn.____../.__________ <br />!:!Uf,j \1 li':;!:.~':.:0i <br /> <br />\:,';,:,I:il'lt; ';V \ ,'."'nlc.\ <br /> <br />f--------- - _______m_______ <br />THE FOLLOWING FEES MA Y APPLY: <br />LATE: $5_00 CANCEL: 550.00 <br />CHECK RETURNED UNPAID: $10.00 <br />................... ......... ..... .............------.... <br /> <br />C~-~\l&----- <br /> <br />President <br /> <br />OS/22/2005 <br /> <br />WHEN ATTACHED TO THE PERSONAL AUTO POLICY THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS Or <br />YOUR COVERAGES AND LIMITS OF L1ABILlTY_ <br /> <br />Visit 21st.com to make policy chnns!c~;, pay vour premium, and more. Register ani in" todayl For Custumer Care ullll(800)443-3100. <br /> <br />IClJ41CII 101/0:;) <br /> <br />21st Centllry hl~-;llrancc Curnpany, 6301 Owcns!Tlouth Ave" Woodland Hilb, CA 91367 <br />