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<br />Interinsurance Exchange of the Automobile Club <br /> <br />Automobile Insurance Policy Coverage and Limits <br />Policy Change Declarations <br /> <br />insurance is in effect only for the vehicles. coverages, and limits of liability shown on this declarations page and as <br />set forth in the insurance policy and endorsements. These declarations. together with the contract and the <br />endorsements in effect. complete your policy. <br /> <br />NAMED INSURED (item 1.) <br /> <br />CI <br /> <br />AUTO POLICY NUMBER <br /> <br />G 6i62548 <br /> <br />BOLDRICK, LORRIE <br />2387 N FLANDERS ST <br />ORANGE CA 92865-2836 <br /> <br />POLICY PERIOD (PACIFIC STANDARD TIME) <br />EFFECTIVE DATE 1 2 - 2 8 - 0 4 12.01 AM. <br />EXPIRATION DATE 5- 5-05 n01 A.M. <br /> <br />SUBJECT OF POLICY CHANGE <br />COVERAGE CHANGE <br /> <br />THIS IS NOT A BILL <br /> <br />This policy change will increase your premium by $43.00 <br /> <br />VEHICLES <br />VEHICLE <br />NUMBER YEAR <br /> <br />MAKE <br /> <br />MODEL <br /> <br />IDENTIFICATION <br />NUMBER <br /> <br />VEHICLE <br />USE <br /> <br />GARAGE <br />ZIP CODE <br /> <br />ANNUAL <br />MILES <br /> <br />LEASED FINANCED <br /> <br />4 <br /> <br />199B <br /> <br />FORD <br /> <br />EXPLORER <br /> <br />1FMZU32EOWZB33B95 PLEASURE <br /> <br />92B65 10.001 - 15.000 <br /> <br />NO <br /> <br />NO <br /> <br />COVERAGES AND LIMITS <br />Coverage is not in effect unless a premium or the word "included" is shown <br /> <br />ANNUAL PREMIUMS <br /> <br />COVERAGES <br /> <br />LIMIT OF LIABILITY <br /> <br />Vehicle 4 Vehicle <br /> <br />Vehicle <br /> <br />Vehicle <br /> <br />Vehicle <br /> <br />Liability <br />Bodily Injury $1,OOQ,0130each person! $1,000,000 each occurrence <br />Property Damage $50,000 each occurrence <br /> <br />S 416 <br />S 182 <br /> <br />Medical <br /> <br />$ 32 <br /> <br />Excess Medical Payments <br /> <br />$5,000 each person <br /> <br />Physical DaM&gO (Actual cash Value unless otherwise staled, less deductible) <br />Vehicle 4 Vehicle Vehicle Vehicle <br />ACV <br />$100 <br />ACV <br />$250 <br /> <br />Vehicle <br /> <br />Comprehensive <br />(Less Deductible) <br />Collision <br />(Less Deductible) <br />Car Rental Expense <br />(per Day) <br /> <br />S 74 <br /> <br />S 326 <br /> <br />APPROVED AS TO CONTENT: <br />~ <br /> <br /> <br />NA <br /> <br />NA <br /> <br />Uninsured Motorist <br />Bodily Injury $15,000 each person/$30,OOO <br />Uninsured & Underinsured Vehicles <br />Uninsured Deductible Waiver <br /> <br />each occurrence <br /> <br />$ 41 <br /> <br />Ancluded <br /> <br />Total Premium <br /> <br />$1073 <br /> <br />"NA" indicates coverage not purchased <br /> <br />Total Annual Premium"' <br /> <br />$1073 <br /> <br />PREMIUM DISCOUNTS <br /> <br />Please refer to the enclosed document entitled <br />"Premium Discounts Applied to your Automobile Policy." <br /> <br />Net PremÎum <br /> <br />$1073 <br /> <br />IT-WM.'\ <br /> <br />Includes all applicable discounts <br />