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r e..ess �ss.r■ RMS' on 2e7Y <br />21st.eom 1 -800 -211 -SAVE . PERSONAL AUTO Renewal <br />POLICY DECLARATION EFFECTIVE 12/15/2006 <br />Named Insured and Mailing Address r--'— <br />Joe Larose --""- <br />Marie Larose <br />9199 Poinsettia Ave <br />`� j 1�'f: o I a� Fi (✓' <br />Fountain Valley, CA 92708 C1pnf DO " I -- <br />-__ Policy -No: 3493189' <br />Id Driverls) Policy Period: From: 12/15/2006 To: 06/15/2007 12:01 AM Pacific <br />Veh Year Make/Model <br />Vehicle ID Number Use <br />Vehicle Discounts/Comments <br />1 2004 HONDA PILOT U( <br />2HKYF18134H568983 W <br />MCD <br />Zip - <br />2 1989 TOYOTA SHORT BED <br />JT4RN81P6K0002342 P <br />MCO <br />92708 <br />3 2004 HONDA CRNLX <br />JHLRD78444C013062 W <br />AOOITIONALVEH <br />92708 <br />MCD <br />92708 <br />Veh Rated Driver <br />Years Tickets <br />License <br />Chargeable Accidents <br />Driver Discounts <br />1 Joe Larosa <br />3 Marie Larose <br />40 0 <br />GOD <br />39 0 <br />coo <br />COVERAGE IS PROVIDED WHERE A PREMIUM <br />AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE. <br />Coverage <br />Limit of Liability <br />Premium <br />A.Bodily Injury Liability $ 100, 000 <br />Includes <br />each person <br />Veh 1 Veh 2 1 Veh 3 <br />$0.90 par vehicle fraud fee $ 300 000 <br />each accident <br />B. Property Dame a Liabilit $ loo, OOo <br />each accident <br />$ 153 $ <br />84 $ 92 <br />$ <br />C. Medical Pa ments $ <br />each parson <br />$ 85 $ <br />57 $ 70 <br />$ <br />Uninsured Motorist $ 100, 000 <br />D. Bodily <br />each person <br />$ $ <br />I $ <br />$ <br />Injury $ 300,000 <br />each accident <br />$ <br />DAMAGE TO YOUR VEHICLE Veh 1 <br />Veh 2 Veh 3 <br />43 $ <br />41 $ 42 <br />$ <br />Actual Cash Value Less Deductible Ded. <br />Ded. Ded. <br />_ Comprehensive S 500 $ <br />Ded. <br />Soo $ Soo $ <br />Collision <br />$ 500 $ <br />500 $ 500 5 <br />$ 26 $ <br />r <br />13 $ 28 <br />$ <br />J. Additional Equipmenty <br />The first sloco is automatically I Included $1,000 $1, 000 1, 000 $ <br />included withcoverage E or F. Additional $ 0 $ 0 $ 0 $ <br />Additional coverage is optional. Total 81, 000 S1. onn e1 nnn <br />Endorsement(s)/Agreement(s) Applicable: <br />TCU -1 (06/04) TCU51ICA (05/05) <br />Loss Payee (LP), Additional Insured (All, Evidence of Insurance (EI) <br />Veh 1 EI CITY OF SANTA ANA PD <br />Veh 1 EI City of Anaheim PD <br />Veh 3 LP CAPITOL AUTO SALES <br />Drivers Not Rated <br />y <br />THE FOLLOWING FEES MAY APPLY: <br />LATE: $5.00 CANCEL: $50.00 <br />CHECK RETURNED UNPAID; 510.00 12/04/2006 <br />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 todayl For Customer Care call "5001443-3100. <br />C_41CA 09:0 21st Century Insurance Company, 6301 Owensmouth Ave., Woodland Hills, CA 91367 <br />4,01ri <br />8,0 <br />