LA ROSA, JOSEPH R. JR. 3A - 2006

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21st Century Insurance t, 21st.com 1 -800 -211 -SAVE PERSONAL AUTO Amendment POLICY DECLARATION EFFECTIVE 07/05/2006 MEMORANDUM COPY Evidence of Insurance and Mailing Address CITY OF SANTA ANA PID 60 CIVIC CENTER PLAZA SANTA ANA, CA 91702 _>r>-CCi—UI Named Insured and Mailing Address Joe Larosa Marie Larosa 9199 Poinsettia Ave Fountain Valley, CA 92708 Policy No: 3493189 vot i aiwvo 10: 12/15/2006 12:01 AM Pacific Time Vehicle(s) and Driverts) Veh Year Make/Model Vehicle ID Number Use Vehicle Discounts/Comments 1 2004 HONDA PILOT LX 2HKYF18134H568983 Zip Mileage 2 1989 TOYOTA SHORT BED JT4RN81P6K0002342 $ 100,000 each person In,50.90 per vehicle fraud fee 3 2004 HONDA CR VLX JULRD78444CO13062 B. Pro art Dome e Liabilit Veh Rated DriverLicars ense Tickets Chargeable Accidents Driver Discounts 1 Joe Larosa $ - Uninsured Motorist$ erson $ 100,000 each person $ 3 Marie Larosa D. Bodil Inur300,000 $ 300, 000 each accident $ COVERAGE IS PROVIDED WHERE A PREMIUM ANIn A I IAAIT nc i IAou 11 A-1 -1 $ I), Evidence of Insurance (EI) Drivers Not Rated Loss Payee LP), Additional Insured (A Veh 1 EI CITY OF SANTA ANA PD Christine Larosa Veh 2 EI CITY OF SANTA ANA PD For Loss Payee information call 1-888-841-8233 C Address inquiries to 21st Century Insurance Company 6301 Owensmouth Ave., Woodland Hills, CA 91367 i 07/13/2006 President WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. TCU4At CA 101/051 C` 21st Century Insurance Company, 6301 Owensmouth Ave., Woodland Hills, CA 91367 - -------•• •-••..�,,� .,, ,1/1/1/,1/ run Int l.V VtHHGt. Coverage Limit of Liability Premium Veh 1 Veh 2 Veh 3 A. Bodily Injury Liability $ 100,000 each person In,50.90 per vehicle fraud fee $ 300,000 each accident $ B. Pro art Dome e Liabilit $ 100, 000 each accident 163 $ 8¢ $ 92 $ C. Medical Pa ments $ each $ 85 $ 57 $ 7o $ - Uninsured Motorist$ erson $ 100,000 each person $ $ S -- D. Bodil Inur300,000 $ 300, 000 each accident $ DAMAGE TO YOUR VEHICLE Veh 1 Veh 2 Veh 3 43 $ 41 $ 42 $ Actual Cash Value Less Deductible Ded. Ded. Ded. Ded. $ E. Comprehensive $ 500 $ 500 $ 500 $ F. Collision $ 500 $ Soo $ Soo $ 26 $ 13 $ 28 $ Uninsured Motorist $ 102 $ 55 $ 123 $ D1. Pro art Dama a DED WAIVE DED WAIVE DED WAIVE $ G. Towin & Labor S 50 each disablement 5 $ 5 $ S S H. Rental Reimbursement S Included Included Included Included J. Additional Equipment per da $ max Included $ 1, 000 $ $ $ $ First 51000 is automatically $1, 000 $1, 000 $ included with coverage E or F. Additional $ 0 $ 0 $ 0 $ Additional coverage is optional. Total $1,000 $1,000 1, 000 Total Premium Per Vehicle $ 424 $ 255 $ 360 $ Endorsements)/Agreements Applicable: Total Premium $ 1,039 I), Evidence of Insurance (EI) Drivers Not Rated Loss Payee LP), Additional Insured (A Veh 1 EI CITY OF SANTA ANA PD Christine Larosa Veh 2 EI CITY OF SANTA ANA PD For Loss Payee information call 1-888-841-8233 C Address inquiries to 21st Century Insurance Company 6301 Owensmouth Ave., Woodland Hills, CA 91367 i 07/13/2006 President WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. TCU4At CA 101/051 C` 21st Century Insurance Company, 6301 Owensmouth Ave., Woodland Hills, CA 91367