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21st <br />Insurance <br />** INSURED'S COPY ** <br />AUTOMOBILE <br />IAP 3493189 <br />NSUREO AND ADDRESS X—t:003 J / a <br />JOE R LA ROSA JR <br />MARIE E LA ROSA <br />9199 POINSETTIA AVE <br />FOUNTAIN VALLEY CA 92708 <br />attached to the Personal Auto Policy, these <br />2 I19991 ACCORD LX <br />3 19891TOYOTA P/U <br />__3 JOE LAROSA <br />2 MARIE LAROSA <br />HMC06654XCO16174 <br />T4RN81P6K0002342 <br />38 <br />36 <br />0 <br />0 <br />RENEWAL DECLARATION OFFER <br />EFFECTIVE 06/15/04 <br />IN THE EVENT PAYMENT IS NOT RECEIVED <br />�BY THE RENEWAL EFFECTIVE DATE NOTED <br />ABOVE, YOUR POLICY BECOMES NULL AND <br />DID. <br />LOSS PAYEE AND/OR ADDITIONAL INSURED AODRESS(SEE REVERSE) <br />** EVIDENCE OF;INSURANCE ** <br />CITY OF SANTA ANA PD <br />60 CIVIC CENTER PLAZA <br />SANTA ANA CA 91702 <br />the current status of <br />GDD <br />GDD <br />081 000010 <br />081 000005 <br />COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE YpE! T 1 VqN z YF11 a A. Bodily Injury <br />..INCLUDES $0.90 PER VEHICLE rR1UD FEE $ 100.000 Each Person $300.000 Each Accident 157 96YRFr NI'. <br />VAiUELE53 E. COMPREHENSIVE <br />DEDUCTIBLE F. COLLISION $ <br />DI. UNINSURED MOTORIST- PD <br />J. ADDITIONAL EQUIPMENT $ <br />FIRST $1000 IS AUTOMATICALLY <br />INCLUDED WITH COMPREHENSIVE OR $ <br />COLLISION. <br />ADDITIONAL COVERAGE IS OPTIONAL $ <br />G. <br />NG& LABOR <br />IH. RENTAL REIMBURSEMENT <br />Each Person <br />DED WAIVE <br />TOTAL $ 1,000 TOTAL <br />INCL. $ 0 INCL. <br />ADD'L $ 0 ADD'L <br />,000 TOTAL $ TOTAL <br />0 INCL. $ INCL. <br />5 <br />5 <br />k -- — - 05/21/04 <br />PRESIDENT DATE <br />MR : Drivers Not rated - STATEMENT OF ACCOUNT FOR POLICY 3493189 - <br />NR:CHRISTINE LAROSA TOTAL PREMIUM ................ S 707.00 <br />CHOOSE THE PAYMENT N YOU PREFER: <br />PAY IN FULL S 707.00 06/15/04 <br />)r2-PAY PLAN <br />S 358.00 <br />06/15/04 <br />S 357.00 <br />08/15/04 <br />)(4-PAY PLAN <br />$ 181.00 <br />06/15/04 <br />S 181.00 <br />07/15/04 <br />81.00 <br />08/15/04 <br />S 180.00 <br />09/15/04 <br />K INCLUDES 54 rtm rAYNENI SEKVILE CNAK6E <br />For Customer Care call 1-800-443-3100, or visit 21st.com to make policy changes, pay your premium. and morel Register today! <br />21st Century Insurance Company 6301 Owensmouth Avenue Woodland Hills, California 91367 K E <br />