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StateFarm <br />State Farm Mutual Automobile Insurance Company 38798-3-A MATCH 00711 MUTL VOL <br />PO Box 2368 DECLARATIONS PAGE <br />Bloomington 1L 61702-2368 <br />PAGE 1 OF 2 <br />NAMED INSURED 00711 <br />55-2001-3 A A POLICY NUMBER 583 7885-D15-55B <br />000712 0058 POLICY PERIOD FEB 24 2025 to OCT 15 2025 <br />MELGOZA, JORGE B & MELGOZA, 12:01 A.M. Standard Time <br />ANNA <br />AST DR APT 51 SAN DIEGO STATE FARM PAYMENT PLAN NUMBER <br />SAN IEGO CCA 92119-2444 <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 />DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. <br />IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED. <br />YOUR CAR <br />2012 HONDA ACCORD 4DR 1 HGCP2F32CA082366 6030BV19 <br />..: A <br />Liability verge <br />$ $ <br />Bodily Injury Limits <br />..: <br />Each Peon, :Each Accident ...: <br />..: <br />............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... <br />$1,000,000 $1,000,000 <br />Froperty Damage Lirt .. .. .. <br />.... <br />Each Accident <br />..: <br />$1 ,}} .... <br />.. ..... <br />D <br />Comprehensive Coverage - $500 Deductible <br />$51.19 <br />Oaliisien coverage - $00 >eductible ....: <br />$22 , ..... <br />H <br />Emergency Road Service Coverage <br />$6.70 <br />U <br />t irxsured Motor Vehicle Coverage .... <br />.. $M.21 <br />Bodily Injury Limits <br />..: <br />Eacl�I Prscn, :Each Accident <br />$500,000 $1,000,000 <br />L11 <br />Urtinsurecl lUlotor Vehille Pro Derma e Covers e <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 Tu Tran Nguyen at 3:55 pm, Mar 12, 2025 <br />Digitally signed <br />Tu Tran byTuTran <br />Nguyen <br />Nguyen 1155559-0700? <br />CONTINUED <br />12960/08381 See Reverse Side <br />155-3966 CA.2 05-2002 (ola025fc) <br />IMON (M 025te) <br />