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21st Century Insurance Page 1 of 2 <br />MsLcoirn 1 -800 -211 -SAVE PERSONAL AUTO Renewal <br />POLICY DECLARATION EFFECTIVE 06/15/2007 <br />Named Insured and Mailing Address <br />Joe Larose <br />Marie Larosa <br />9199 Poinsettia Ave <br />Fountain Valley, CA 92708 <br />A -goo 6 -00 /* <br />A , P-00( - 00 1 - () 1 <br />Policy No. 3493189 <br />Policy Period: From: 08/15/2007 <br />To-- 1211 5120W 12•M AU Pm -Wit- Thvmu <br />%1%0 V U.FW%%JFG g-3 rW%%# V ILOCLI WWr=r%C A% rrWIMILOM AMU J% UM1 1 Wr uAtslu I T AM *HVVVN <br />N a- <br />RE <br />2WW181341 <br />W <br />MCD 92708 <br />. <br />3 <br />1 <br />2004 <br />HOLM PKIN LX <br />4,000 <br />2 <br />2008 <br />TOYOTA TUNIM DOU <br />6TBETNIM662072 <br />W <br />MCD 92708 <br />BAD <br />B. Property Damage Liability 106,000 each accident <br />$ 61 <br />V"W <br />C. Medical Payments - each person <br />$ <br />V <br />I <br />Mme Lalesa <br />39 0 <br />goo <br />2 <br />Joe Lmsa <br />41 0 <br />600 <br />%1%0 V U.FW%%JFG g-3 rW%%# V ILOCLI WWr=r%C A% rrWIMILOM AMU J% UM1 1 Wr uAtslu I T AM *HVVVN <br />I -UK I "t GuMtKAtib. <br />RE <br />. <br />3 <br />7 <br />A. Bodily Injury Liability 100,000 each person <br />km*xks $0.90. vehleb fraud fee 300,000 each accident <br />$ 103 81 <br />B. Property Damage Liability 106,000 each accident <br />$ 61 <br />81 <br />C. Medical Payments - each person <br />$ <br />$ <br />UrtrAtured Motorist loo, 000 each person <br />Q. Bodily "iry 300, 000 each accident <br />$ 19 <br />4 35 <br />DAMAGE TO YOUR VEHICLE Veh - 1 Veh 2 <br />$ 16 <br />45 <br />Actud Cwh VWw Lma Dadvabb Ded. Ded. Ded. Ded. <br />E. C;omprahensive $ Soo $ Soo $ <br />F. Collision $ Soo $ 500 $ <br />$ 65 <br />$ 132 <br />Uninsured Motorist <br />131. Property Damage DED WAIVE PED WAIVE <br />5 <br />5 <br />G. Towing& Labor $ so each disablement <br />Included <br />Included <br />Included <br />Included <br />H. Rental RehrdxwswTwnt $ par day; $ max <br />$ <br />J. Additional Equipment Included $1,000 $1,00o $ $ <br />The fist $1000 is autornatically Additional S 0 0 <br />kv*jded with coverage E or F. <br />Additional covers" is opdonal. I Total $1,000 $1,000 <br />1 Told Prarnlwn Per Vaidde 1$ 269 379 $ <br />If the Installment b <br />,l 60 eft I" nhurna may apply. Total Pmn*m */9'V- <br />6 <br />vement(s)/Agreernent(s) Applicable: <br />1(06/04) TCU51 ICA (05/05) <br />Low Payee ILP), Additional Insured f, <br />Veh 2 Al City Of Santa Ana <br />Veh 2 Al City of Anaheim <br />of Insurance (EI) <br />Al <br />Drivers Not Ra�M <br />Of -WA"05/21/2007 <br />WHEN ATTACHED TO THE PERSONAL AUTO POLICY. THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT <br />THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABKM. <br />Visit 21 st.corn to make policy dw*m, pay your premium, and more. Register online todayl For Customer Care caN 1(800)443-3100. <br />TCU41CA 409=1 21st CanturY Ifutwarme Company, 6301 Owenernouth Ave., Woodlend Hills, CA 91367 <br />