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<br />I A'-''-'A CUN'"'L" 'ING <br />IVlay Z'::J UI:S UL:Zl:Sp vv v <br />.. ~~-c':l.-c~ 1.5= ~~ HALVERSON 9. 989-7831 <br />INSURED COpy 070522 140355 <br /> <br />r . ~-444-OO42 <br /> <br />p.3 <br />PAGEl <br /> <br />AGENT <br /> <br /> l..,...c" '0 "0&1,, POllOI ~~ <br />P'OlI CY NUMIIE" IEl'FEeTl VI; 1')(Jil1'i.....1ON T A GaIT' Sf CITY U <br />OAn ~TE <br />PC121328 04/20/07 071 0 1/08 1 55077 04 <br /> <br />DECLARA TIONS <br /> <br />'b <br /> <br />U'III GARD I NSUlANCE CO. <br />P.OBDX 90701 <br />~EVUe. YV~ 98009-070' <br /> <br />~ <br /> <br />(510) 548-8200 <br />F I DEL I TY I NSlRANCE SERV I CE r NC <br />PO BOX 2096 <br />BERKELEY CA 94702 <br /> <br />Effective .t 12.-01 ".M. stendard time on the elates shOWn <br />above lit tile address of the named insured this <br />AMENDED OECLARA T I ON <br />replaces all prior declarations. if any. and with policy <br />provisions and endorsements, if any issued to form a part <br />thereof completes this PERSONAL UMBRELLA UABllIT' <br />POLICY. <br /> <br />NMED INStJRED AN;) MAilING ADDRESS <br /> <br />REX HAl. VERSCN <br />255 CASCADE FALLS OR <br />FOLSOM CA 95630 <br /> <br />COVERAGE <br />PERSONAl LIABILITY <br />excess UNlNSlHo AlII) <br />UNOERINSl.RD MOTORIST <br /> <br />UMITS CFLlABIUTV <br />$1,000,000 EACH OCClRU:NCE <br />NJT COVERED <br />~ OF ~DEAl..YIHC IN~ <br />POlicy Number ComD8ny <br />UH125608 UNIGARQ <br />20021251 l-"IIGARD <br /> <br />RET AI NED lIMT <br />$ 250 <br /> <br />Tvpe of Poliev <br /> <br />PERSONAL LIABILITY <br /> <br />~UTO LIABILITY <br />L , AS I L /TV <br />MISC. AUTO LIABtLl TV <br /> <br />UA125606 <br />10136659 <br /> <br />~ I GARD <br />LNI GAR[) <br /> <br />limits of l.iabilitv <br /> <br />$ 300,000 SINGLE LIMIT <br />$ 500,000 SiNGlE LIMIT <br /> <br />$ 500,000 SINGLE LIMIT <br />$ 500,000 SINGLE LIMIT <br /> <br />TOTAL PREMIUM <br /> <br />$165.00 <br /> <br />=NOORSEMeNTS fattaehe<t to and forming a p<<t thereof): <br /> <br />103272 03-05. 103270 03-05. 1~8105 03-05, 154106 03-05. UNO 0 0 1 10-01, <br />.Jtf0023 05-05 <br />iEH I CLE ADDEO <br />IEH I CLE a-tANGEo <br />~ECREA T I ONAL VEti I CLE l..MlERL Y I N3 ADDEO <br /> <br />ADD I T I ONAL PREM I UM THI S ~seMENT <br /> <br />$.00 <br /> <br />COUNTEllSIGNED 8V <br /> <br />O....TI! <br /> <br />5/22/07 <br /> <br />150 <br /> <br />SAC <br /> <br />AGI;HCY <br /> <br />30$ EDmo~ Ie-I!; "0:1271 R[V '-lit <br /> <br />