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21st Century Insurance <br />21st.com 1 -800 -211 -SAVE <br />Named Insured and Mailing Address <br />ti Joe Larose <br />Marie Larose <br />9199 Poinsettia Ave <br />Fountain Valley, CA 92708 <br />Il�l���tltll�ttll{���Ittl���ltl�tltlrltrtlltt�l�lttl�lrtl��ltl <br />PERSONAL AUTO Renewal <br />POLICY DECLARATION EFFECTIVE 12115/2007 <br />A -?U0-"7 y� <br />Page 1 of 2 <br />Policy No: 3493189 <br />Policy Period: From: 12/15/2007 <br />To: 06/15/2008 12:01 AM Pacific Tim <br />Veh <br />Year <br />"a/Model <br />Vehicle ID Number <br />Veh 1 <br />Use <br />Vehicle Discounts/Comments _ zip <br />Mileage <br />1 <br />2004 <br />HONDA PILOT LX <br />2HKYF18134H568983 <br />$ <br />W <br />MCO 92708 <br />4.001 <br />2 <br />2006 <br />TOYOTA TUNDRA DOU <br />5TBET341 X6S552072 <br />C. Medical Payments <br />W <br />MCD 92708 <br />8,00( <br />Veh <br />Rated DriverLiceease <br />Uninsured Motorist <br />D. Bodily Injury <br />$ loo, 000 each person <br />$ 300,000 each accident <br />Tickets <br />Chargeable Accidents <br />Driver Discounts <br />1 <br />Marie Larose <br />Veh 1 Veh 2 <br />40 <br />0 <br />1 POICOLL <br />GDD <br />2 <br />Joe Larosa' <br />E. Comprehensive <br />41 <br />0 <br />$ 500 $ 500 $ $ <br />GDD <br />Coverage <br />Limit of Liability <br />Premium <br />Veh 1 <br />A. Bodily Injury Liability <br />Includes $0.90 per vehicle fraud fee --- <br />$ loo, 000 each person <br />$ 300,000 each accident <br />$ 154 <br />S 81 <br />$ <br />$ <br />B. Property Damage Liability <br />$ loo, 000 each accident <br />$ 98 <br />$ 81 <br />$ <br />$ <br />C. Medical Payments <br />$ each p2rson <br />$ <br />$ <br />$ <br />$ <br />Uninsured Motorist <br />D. Bodily Injury <br />$ loo, 000 each person <br />$ 300,000 each accident <br />$ 40 <br />$ 35 <br />$ <br />$ <br />DAMAGE TO YOUR VEHICLE <br />Veh 1 Veh 2 <br />30 <br />$ 45 <br />$ <br />$ <br />Actual Cash Value Less Deductible <br />Ded. Ded. Ded. Ded. <br />E. Comprehensive <br />$ Soo $ 500 $30 <br />F. Collision <br />$ 500 $ 500 $ $ <br />$ 123 <br />$ 132 <br />$ <br />$ <br />Uninsured Motorist <br />D1. Property Damage <br />DED WAIVE IDED WAIVE 1 <br />5 <br />$ 5 <br />$ <br />$ <br />G. Towing & Labor <br />$ 5o each disablement <br />Included <br />Included <br />Included <br />Included <br />H. Rental Reimbursement <br />$ per day; $ max <br />$ <br />$ <br />$ <br />$ <br />J. Additional Equipment <br />The first $1000 is automatically <br />included with coverage E or F. <br />Additional coverage is optional. <br />Included $1, 000 $1, 000 $ S <br />Additional $ 0 $ 0 $ $ <br />I Total $1, 000 $1, 000 $ S <br />$ <br />$ <br />$ <br />$ <br />Total Premium Per Vehicle <br />$ 450 <br />$ 379 <br />S <br />$ <br />If the installment bill plan is used, a service charge may apply. <br />Endorsements)/Agreement(s) Applicable: <br />TCU -1 (06/04) TCU511 CA (05/05) <br />Loss Payee (LP), Additional Insured (AI), Evidence of Insurance (EI) Drivers Not Rated <br />Veh 1 EI CITY OF SANTA ANA PD <br />Veh 1 EI City of Anaheim PD <br />Total Premium $ <br />Veh 2 LP Toyota nnotor Credit torp <br />THE FOLLOWING FEEIS) MAY APPLY:11/15/2007 <br />QCS <br />� <br />LATE: $5.00 PAYMENT RETURNED (NSF►: $10.00 <br />CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE: $4.00 President <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 todayl For Customer Care call 1(800)443-3100. <br />TCU41CA 109/051 21st GenturV Insivance Company, 6301 Owensmouth Ave., Woodland Hills, CA 91367 <br />