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~ 21 ~~st Century Insurance <br />~_~_ tst.com 1-800 211-SAVE <br />Named Insured and Mailing Address <br />Joe Larosa <br />9199 Poinsettia Ave <br />Fountain Valley, CA 92708 <br />v..u,.t..t_t ....a n.:..,.d..t <br />PERSONAL AUTO Renewal <br />POLICY DECLARATION EFFECnvE 06/15/2005 <br />Policy No: 3493189 <br />Policy Period: From: 06/15/2005 To: 12/15/2005 12:01 AM Pacific Time <br />"' Veh Year Model Vehicle ID Number Use Vehicle Discounts/Comments Zip Mileage <br />1 2004 PILOT LX 2HKYF18134H568983 P MCD 92708 10,000 <br />2 1989 BHORTBED DELUXE JT4RN81P6K0002342 W MCD 92708 9,000 <br />Veh Rated Dri ver Licensed Ticlcets Chargeable Accidents Discounts <br />1 Marie Larosa __ 37 0 GOD <br />2 Joe Larosa 39 0 GDD <br />COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE. <br /> Premium <br />-- <br />Coverage Limit of Liability Veh 1 Veh 2 ___, , <br />__ <br />A. Liability Bodily Injury _ __ <br />S 100, 000 each person <br />Includes 50.90 per veh~de fraud fee $ 300 000 each accident $ $ ,_ $ S __._ <br />B. Pro ert Dama e S loo, o0o each accident S S S S <br />C. Medical Pa meets each person <br />$ $ _ S S S __. <br />Uninsured Motorist _ <br />__ <br />S 100, o0o each person <br />. Bodily <br />Ir1u~ <br />D 000 each accident <br />$ 700, _ S__ _ ___ S ____. _.._ S _ _ __ S . ___ <br />_ <br />_ <br />DAMAGE TO YOUR VEHICLE . <br />r -- <br />Veh 1 Veh 2 ___ _ <br />Actual Cash Value Less Deductible Ded. Ded. Ded. Ded. <br />E. Comprehensive S Soo S soo S S S S S S <br />F. Collision S soo $ soo S S S 5 S S_ _ <br />Uninsured Motorist <br />D1. Pro ert Dama e DED WAIVE DED WAIVE S $ $ S <br />G._Towing & Labor $ so each disablement Included Included Included Included <br />H. Rental Reimbursement $ _ ,_per daY, __ S max_ __ _ $ __ S S _„_ S <br />J. Additional Equipment Incluued S-I , o0o S) , o0o s' $ <br />The first 51000 is automatically <br />Additional $ 0 $ 0 $ $ <br />inoluded with aovemge E or P. <br />Additional ooverago is opfional. TUtal $1,000 $t, 000 $ _.__$__ $ ____. _$,_.,._. _$____ ..____$ <br /> Total Premium Per Vehicle S $_________ S ___ S ___ <br /> Total Premium S <br />Endorsememisj/Agreementls) Ap plicable: <br />TCU-1 (06/04) TCU 511CA (05105) <br /> KUVE~I: 6\S i( ; i?KN; <br />Loss Payee (LPI. Additional Insured (All, Evidence of Insurance (EI) ~~~ ~; <br />Vch 1 EI CITY OF SANTA ANA PU __ __ <br />Veh 2 EI CITY OF SANTA ANA PD ~ !.. Ir ~ i ~ ~ ~~ <br />\» ,taint ._ '~il.'t. .r <br />THE FOLLOWING FEES MAY APPLY: ~~_~\ 1~~ ~,__ 05/22/2005 <br />LATE 55.00 CANCEL: 550 00 , A+ <br />CHECK RETURNED UNPAID: 810 00 President <br />WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARAI IONS COMPLETE THE POLICY AND REPRESENT" THE CURRENT STA iUS OF <br />YOUR COVERAGES AND LIMITS OF LIARILITV_ <br />Visit 21 sLCOm to malcn policy changes, pay your premium, and more. Register online today) For Qislum er Care call 11800)443-3700. <br />rcuni Cn lot/os~ 21st Century Insurance Company, 6301 Owensm oath Ave., Woodland Hills, CA 91367 <br />