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®21st Century Insurance <br />21st.eom 1 -800 -211 -SAVE PERSONAL AUTO Renewal <br />POLICY DECLARATION EFFECTIVE 12115/2005 <br />Named Insured and Mailing Address <br />Joe Larose <br />9199 Poinsettia Ave <br />Fountain Valley, CA 92708 <br />Policy No: 3493189 <br />Policy Period: From: 12/15/2005 To: 06/15/2006 12:01 AM Pacific Time <br />Vehiclels) and Drivers) <br />$ <br />$ <br />100.000 <br />300 000 <br />each person <br />each accident <br />YOUR VEHICLE <br />Veh <br />Year <br />Model <br />Vehicle ID Number <br />Use <br />Vehicle Discounts/Comments <br />Dad. Ded. Ded. <br />Zip <br />Mileage <br />1 <br />2 <br />2004 <br />1989 <br />PILOT LX <br />SHORT BEO GELLIXt <br />2HKYF18134H568983 <br />JT4RNO1P6K0002342 <br />P <br />V1 <br />MCO <br />MCD <br />92708 <br />92708 <br />10,000 <br />9,000 <br />Veh <br />Rated Driver <br />Licensed <br />Tickets <br />Chargeable Accidents <br />Discounts <br />1 <br />2 <br />Joe Larosa <br />39 <br />0 <br />GDD <br />j <br />Coverage Limit of Liability Premium <br />Veh 1 Veh 2�T—� <br />1 A. Liability Bodily Iniury 1 $ 100, 000 each person I <br />Motorist <br />$ <br />$ <br />100.000 <br />300 000 <br />each person <br />each accident <br />YOUR VEHICLE <br />Veh 1 <br />Veh 2 <br />is Less Deductible <br />Dad. I <br />Dad. Ded. Ded. <br />sive <br />$ <br />500 I $ <br />Soo $ $ <br />Motorist <br />$ 28 1 $ <br />14 1 $ <br />J. Additional EquipmentIT0101 <br />Included $1,000 $1, 000 $ $ <br />The test 11000 is automatically Additional $ 0 $ 0 $ $ <br />included with coverage E or F. <br />Additional coverage Is optional. S 1, 000 91.000 S < < < e e <br />Endorsements)/Agreement(s) Applicable: APPR®v <br />TCU -1 (06/04) TCU511CA (05/05) bU AS T'O pORN, <br />Loss Payee (LP), Additional Insured IAO, Evidence o1 Insurance HEI) Lat;ra Stitt <br />" <br />As Slsc��l�� - --` <br />Veh 1 EI CITY OF SANTA ANA PD t i <br />Veh 2 EI CITY OF SANTA ANA PD slant City 4tlnr:, <br />(THE FOLLOWING FEES MAY APPLY: <br />LATE: $5.00 CANCEL, 450,00- - �''"'� --�� 11/20/2005 <br />'CHECK RETURNED UNPAID: $10.00 President <br />WHEN ATTACHED TO THE PERSONAL AUTO POLICY. THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS OF <br />YOUR COVERAGES AND LIMITS OF LIABILITY. <br />Visit 21 st.com to make policy changes, pay your premium, and more. Register online today) For Customer Care call 1(800)4433100. <br />'41CA IMM/ 21c1 Century Inmoanre Cnmpanv. (1301 Ovvensmmoh Ave.. Wnndland Hitic. CA 913(17 <br />