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21ST CENTURY 818 7041407 09/02 '08 18:13 NO.611 03/03 <br />21st Century Insurance Page 2 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 />Mane V Weldy <br />Scott Weldy <br />22671 Revere Rd <br />El Toro, CA 92630 <br />Policy No: 3772950 <br />Policy Period: From: 04/30/2008 <br />To: 10/31/2008 12:01 AM Pacific Time <br />Vehi <br />ew. <br />and Drive a <br />Veh <br />ear <br />MakeNadel <br />Vehicle iD;Mmber <br />U* 6 <br />Veh' Uiscaur!00i*mM*nti <br />Zi <br />Miles a <br />5 <br />1957 <br />CIaFVR%ET CAMARO <br />124377059395 <br />P <br />MCD ADDITIONALVEH <br />92630 <br />2,000 <br />Veh <br />I Rated:Driver <br />Year's <br />Licensed <br />Tac4ft <br />CtiatgeabNe ACCid0i* <br />Driver DWoounts <br />COVERAGE <br />15 PROVIDED WHERE A PREMIUM AND A LIMIT <br />OF LIABILITY ARE SHOWN FOR THE COVERAGE. <br />Coverage <br />Urn of'Llability <br />V M <br />A. Bodily <br />krclu�as$0.90 <br />Injury Liability <br />pervehicle fraud fee <br />$ 1.00, 000 each person <br />$ 300,000 each accident <br />$ 26 <br />$ <br />$ <br />$ <br />B. Oropery <br />DamB a Liablli <br />$ ioo 000 each accident <br />$ 35 <br />$ <br />$ <br />$ <br />C. <br />edical Payments <br />$ 5,000 each eerson <br />$ 13 <br />$ <br />$ <br />$ <br />Uninsured <br />Motorist <br />$ 100,000 each person <br />Ded. <br />Motorist <br />J. Additional <br />Equipment <br />Included $ $ <br />$ <br />$ <br />7helfirst <br />$1000 is automatically <br />Additional $ $ <br />$ <br />$ <br />inc�ded <br />with coverage E or F. <br />Additional <br />oovera a is o tlonal. <br />Total $ $ <br />S <br />$ <br />$ <br />$ <br />$ <br />$ <br />Total Premium Per Vehicle <br />$ 91 <br />$ <br />1 <br />$ <br />If the <br />installment bill plan is used, a service charge may apply. <br />Total Premium $ 3,077 <br />Endor�ament(s)/Agreement(s) Applicable: <br />Loss Payee (LP), Additional Insured (AI), Evidence of Insurance (EI) Drivers Not Rated <br />THE PbLe ovrlihta l e biAy y <br />LATE a' IcV31AI�i�ReTurt t b ivsF� _...._. �70;9F �- ' --� 03/31/2008 <br />11N L ' Si1rl�I� 1N 'I'ai1 EN`I, 9Yf. 4,'rAm sER1/tc9&, A Presldent <br />WHEN ATTACHEO 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(WO)443-3100. <br />TOV410A (W05) 21at Century Insurance Company, 6301 Owensmouth Ave., Woodland Hills, CA 91367 <br />Fax from : 818 7041407 09/02/08 18:27 Pg: 3 <br />