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21ST CENTURY 818 7041407 09/02 '08 18:13 N0.611 02/03 <br />21st Century Insurance Page 1 of 2 <br />21st.com 1-800-211-SAVE PERSONAL AUTO Renewal <br />POLICY DECLARATION EFFECTIVE 04/30/2008 <br />Named Insured and Mailing Address <br />Marie V Weldy <br />$Cott Weldy <br />22671 Revere Rd <br />El Toro, CA 92630 <br />Policy NO: 3772950 <br />Policy Period: From: 04/30/2006 <br />To: 10/31/2008 12:01 AM Pacific Time <br />Vehic <br />e(s) and'brive s <br />Veh <br />ear <br />MakolModel <br />Vehicle 10.NuMber <br />Use <br />Vehicle DiscounWComMQ' hW. <br />Zip <br />Mlfea e <br />1 <br />'1961 <br />CoNv volvo 644 <br />A61289410 <br />P <br />MCD <br />92630 <br />1.000 <br />2 <br />�m <br />000GE DAKOTA QUA <br />157HL48X126531895 <br />W <br />MCD <br />92630 <br />51000 <br />3 <br />1000 <br />VOLKSWAGEN NEW BEETLE <br />3VwDD21C0YM49s180 <br />W <br />MCD <br />92630 <br />10.000 <br />4 <br />k02 <br />DODGE DURANGO SL <br />184HS58N32F122987 <br />W <br />M_CD <br />92630 <br />12,000 <br />Veh <br />+ _ <br />Rated Driver <br />Yoars: <br />License <br />TlCkafs <br />Chargeable Accidents <br />"r9 <br />_ <br />brlvertllt:counts <br />1 <br />koben Weldy <br />Jennifer <br />02 <br />0 <br />MXP <br />2 <br />Weldy <br />oa <br />0 <br />GDo <br />3 <br />Mario V Wcidy <br />33 <br />1 <br />MXP <br />4 <br />colt weldy <br />34 <br />0 <br />Goo <br />�%dy <br />VC 10 rRVvI wrw vvr7CrCC M r-MCIVIIVM MILL M LIMI I Vr LIMUILI IT PV'Ct 0NUVVN r-UM I HL GVVtKA0t. <br />Coverage <br />LJmIt cf Liability <br />Rrerrriurrl <br />Veh 1 <br />Veh 2 <br />Veh 3 <br />Veh <br />4 <br />A. <br />In01 <br />dily Injury Liability <br />ee $0.90 per vehicle fraud fee <br />$ 100, 000 each person <br />$ 300,000 each accident <br />$ <br />213 <br />$ <br />119 <br />$ <br />116 <br />$ <br />64 <br />S. <br />o e Damage Liability <br />$ 100, 000 each accident <br />$ <br />179 <br />$ <br />145 <br />$ <br />154 <br />$ <br />93 <br />C. Medical <br />Payments <br />$ 5, 000 each person <br />$ <br />94 <br />$ <br />73 <br />$ <br />107 <br />$ <br />30 <br />D. 6lodil <br />ninsured Motorist <br />In' <br />$ 100,000 each person <br />$ 300,00 each accident <br />$ <br />83 <br />$ <br />62 <br />$ <br />87 <br />$ <br />22 <br />DAI <br />IAGE TO YOUR VEHICLE <br />Veh 1 <br />Veh 2 <br />Veh 3 <br />Veh 4 <br />$ <br />is <br />$ <br />75 <br />$ <br />71 <br />$ <br />42 <br />AcW*f <br />Cash Value Less Deductible <br />Dad. <br />Ded, <br />Ded. <br />Ded. <br />E. Coin <br />rehenslve <br />$ 0 <br />$ 100 <br />$ 100 <br />$ 100 <br />F. dollision <br />$ 100 <br />$ 100 <br />$ 100 <br />$ 100 <br />$ <br />93 <br />$ <br />399 <br />$ <br />438 <br />$ <br />202 <br />Uninsured <br />D1. <br />Motorist <br />O e Damage <br />DED WAIVE <br />DED WANE <br />IDEDWAIVE <br />DED WANE <br />$ <br />3 <br />$ <br />2 <br />$ <br />3 <br />$ <br />2 <br />G. <br />wing & Labor <br />$ 5o each disablement <br />Included <br />Included <br />Included <br />I Included <br />H. Rental <br />Reimbursement <br />per day: $ <br />max <br />$ <br />$ <br />$ <br />$ <br />J. Additional <br />The <br />included <br />Add <br />Equipment <br />Past $1000 is automatically <br />with Coverage E or F. <br />oral coverage is optional. <br />Included $1, 000 $1, 000 $1, 000 $1, 000 <br />Additional $ 0 $ 0 $ 0 $ 0 <br />Total $1 000 $1,000 $1 000 $1 000 <br />$S <br />If the installment <br />Total Premium Per Vehicle <br />bill plan is used, a service Charge may apply. <br />$ <br />680 <br />Is <br />$ 875 , <br />$ <br />975 <br />$ <br />455 <br />Total Promlum $ <br />I Endortement(s)/Agreement(s) Applicable: <br />TCU-� (06104) TCU511CA (05/05) <br />Loss Payee (LP), Additional Insured (AI), Evidence of Insurance (EI) Drivers Not Rated <br />Veh 2 LP Bank Of The West /J <br />Veh 3 LP VW Credit CIO Pdp <br />THE FbLLOWfND FEt(S) M74't' APPC:Y <br />LAtE s5iltr PAYMENT 11RNED(MSF') $t0v0F} �(---->1� 03131/2008 <br />:Ci1Nt:;55diNt� IF1:jTAt.tNIE1kT:B1tXLihlk$.iiititAtGI.` `�.00 President <br />WHEN ATTACHED TO THE. PERSONAL AUTO POLICY, THESE DECLARATION$ COMPLETE THE POLICY AND REPRESENT <br />THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. <br />Visit 21 st.com to mako policy changes, pay your premium, and more_ Register online today! For Customer Care call 1(BW)443.3100, <br />TCu11CA (oWs) 21 st Century Insurance Company, 6301 Owensmouth Ave., Woodland Hills, CA 91367 <br />Fax from : 818 7041407 09/02/08 10:27 Pg: 2 <br />