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Page 1 of 2 <br />kPERSONAL AUTO Renewal <br />AmeriGas} international Caparaies POLICY DECLARATION EFFECTIVE 12/15120088 <br />I --e Fm.W*t l by rMkx.,+».n s at Arroir- n z WryxtbmM 0,.W, 4r <br />Named Insured and Mailing Address €' <br />r <br />Joe Larosa <br />Made Larosa <br />9199 Poinsettia Ave <br />Fountain Valley, CA 92708 <br />d <br />1 Marie Larese 41 0 1 POICOLL GOD <br />2 Joe Lassa 42 a GDO <br />CIJVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE. <br />Govereg <br />Limit of: Liabiflty Pretstium <br />A. Bodily Injury Liability 100,000 each person <br />includes $0.90 per vehicle fraud fee $ 300,000 each accident $ 154 $ 81 , <br />B. Property EJarnaqq Liabilfty 100,000 each accident $ 98 $ so S <br />$ $ <br />C. `iltledlcal �' merits $ each neon <br />Uninsured Motorist $ 100,000 each person <br />D. Bodily Injury $ 300,000 each accident $ 40 $ 35 $ <br />DAMAGE TO YOUR VEHK3.E Veh 1Veh 2 <br />Aetual Cash Yam Casa Deduct" Ded, De;d. Deli. Ded. <br />E. Comprehensive ' $ 500 $ 500 $ $ S 30 $ 45 $ <br />F. Collision $ Soo $ 500 $ $ $ 123 $ 132 $ $ <br />Uninsured Motorist <br />D1. P!pperty Damage DED WAIVE DED AIVE _ $ 5 $ 5 $, $ <br />G. Roadside Assistance $ 75 each disablement Included Included Included Included <br />Rental per day ue $ $ $ <br />H. Reimbursement I max $ 1 $ 1 $ $ $ $ $ $ <br />J. Additional Equipment Included $1,000 $1, ofio $ <br />The first 01000 is automatically Addftionel" $ 0 $ 0 $ $ <br />Included with coverage E or E. <br />Additional cqX!!EW iso tronas. Total 1,000 $1,000 $ $ $ $ $ $ <br />Total Presrtkon Per VeWe 1,$ 450,:$ 37$ $ $ <br />If the installment bill plan is used, a service charge may apply. Total Premium $ <br />Endorsements)/Agreement{s) Applicable: t, } <br />TCU -1 {06/04) TCU511CA (05/05) <br />Loss Payee (LP), Additional Insured IA]), Evidence of Insurance {E) Drivers Not Hated <br />Veh 1 EI CITY OF SANTA ANA PD <br />Veh 1 El City of Anaheim PD <br />Veh' 2 LP Toyota Motor Credit Corp <br />t o li sa ±tlrr � PA111YIEIY I f � ED 4m S i t).iNi ,. 11115/2008 <br />Pealent <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 LIABILITY. <br />Visit 21 st.com to make policy changes, pay your premium and more. Register online todeyl For Customer Gare call 1-800-443-3100. <br />TC041CA 109PSt 21st Century insurance Company, 6301 Owensmouth Ave., Woodland Hills, CA 91367 <br />