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"51faterarm <br />IM)State Farm Mutual Automobile Insurance Company <br />.. . " PO Box 2368 <br />Bloomington IL 61702-2368 <br />NAMED INSURED 00711 <br />55-2CC1-3 A E <br />000712 0058 <br />MELGOZA, JORGE B & MELGOZA, <br />ANNA <br />6867 GOLFCREST DR APT 51 <br />SAN DIEGO CA 92119-2444 <br />DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. <br />IF AN AMOUNT IS DUE. THEN A SEPARATE STATEMENT IS ENCLOSED. <br />38798-3-A MATCH 00711 MUTL VOL <br />DECLARATIONS PAGE <br />PAGE 1 OF 2 <br />POLICY NUMBER 583 7885-D15-55B <br />POLICY PERIOD FEB 24 2025 to OCT 15 2025 <br />12:01 A.M. Standard Time <br />STATE FARM PAYMENT PLAN NUMBER <br />1235506212 <br />AGENT <br />LAZARO INSURANCE AGENCY INC <br />3924 EL CAJON BLVD <br />SAN DIEGO, CA 92105-1023 <br />PHONE: (619)229-6799 <br />YOUR CAR <br />YEAR MAKE MODEL BODY STYLE VEHICLE ID. NUMBER CLASS <br />2012 HONDA ACCORD 4DR 1 HGCP2F32CA082366 6030BV19 <br />A <br />Liability Coverage <br />$68& 88 <br />Bodily Injury Limits <br />Each Person, Each Accident <br />$1,000,000 $1,000,000 <br />Property Damage Limit <br />Each Accident <br />$1,000,000 <br />D <br />Comprehensive Coverage - $500 Deductible <br />$51.19 <br />G <br />Collision Coverage - $500 Deductible <br />$ 2 .79 <br />H <br />Emergency Road Service Coverage <br />$6.70 <br />U <br />Uninsured Motor Vehicle Coverage <br />$259.21 <br />Bodily Injury Limits <br />Each Person, Each Accident <br />$500,000 $1,000,000 <br />U1 <br />Uninsured Motor Vehicle Property Damage Coverage <br />$& 13 <br />IMPORTANT NOTICE <br />For your protection California law requires the following to appear with this policy: Any person who knowingly presents <br />false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is <br />guilty of a crime and may be subject to fines and confinement in state prison. <br />Replaced policy number 5837885-55A. <br />Notice of insurance information collection practices - personal, family, or household insurance transactions: <br />We may collect customer information from persons other than the Individual or individuals applying for coverage. Such customer <br />information as well as other personal or privilegedInformation subsequently collected may, In certain circumstances, be disclosed <br />to third parties without your authorization as permitted by law. <br />You have the right to submit a written request to access, correct, amend, or delete your personal information and the right to <br />receive a response within 30 days of submitting your request. If we deny your request, you have the right to file a statement <br />with us containing the information you feel is accurate and fair along with the reasons you disagree with our denial. Instructions <br />on how to file such request and our full privacy notice can be found www.statefarm.com/customer-care/privacy-security/privacy <br />or contact your State Farm Agent. <br />Your total renewal premium for APR 15 2025 to OCT 15 2025 is $1,003.48. <br />APPROVED <br />By Tar Tram Nguyen at : a a pm, Mar 12, 202 <br />Digitally signed <br />Tu Tran by Tu Tran <br />Nguyen <br />Nguyen i155559-0700? <br />161610111►1I1A. <br />12960/08381 See Reverse Side <br />155-3666 CA.2 05-2002 (ola025fc) <br />11SXON (ola025te) <br />