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C#CenturPERSONAL AUTO Renewal <br />insurance POLICY DECLARATION EFFECTIVE 06/15/2009 <br />A -,t0-)— Ott) -1)1 <br />Named Insured and Mailing Address <br />Joe Larose 2W7 JUN 15 PH :1'. 24 <br />Marie Larose 06/11/0 09:00 RCM <br />9199 Poinsettia Ave <br />Fountain Valley. CA 92708 CCITY . 1 f C, � .-.I,-, ANCNA <br />ILin„Idlndil.,,l,d,nl,htl,IJ,dl6„IJnI,Ld,ll,l <br />Page 1 of 2 <br />Policy No: 3493189 <br />Policy Period: From: 06/15/2009 <br />To: 12/15/2009 12:01 AM Pacific Time <br />Valli els) and D&er(s) <br />Limit of Liability <br />' Premium'. - <br />Veh 1 <br />Veh 2 <br />Veh <br />Year <br />Make/Model <br />Vehicle ID Number <br />Use <br />': Vehicle DiscountslComments <br />Zip <br />Miie�e <br />1 <br />2 <br />2004 <br />2006 <br />HONDA PILOT LX <br />TOYOTA TUNDRA DOU <br />2HKYFI8134H568983 <br />5TBET341X6S552072 <br />W <br />( W <br />MCD <br />MCD <br />$ each <br />92708 <br />92708 <br />8,170 <br />7,449 <br />Veh <br />Rated Driver <br />S <br />Yea <br />License d <br />Tickets <br />Chargeable Accidents <br />_..� Driver Discounts <br />S <br />1 <br />2 <br />Madelarosa <br />Joe Larose <br />Veh 1 1 Veh 2 <br />41 <br />43 <br />0 <br />0 <br />1 POICOLL <br />GOD <br />GOD <br />Actual Cash Value Less Dedumibla <br />MWAURU-11XIib'UiOl91Nae149aaaiSmLaOAlIIah” wi\01twig 11[tVVta]=5FAV INN W".1:4i4:181"Ui Ems] :•rAmI=01NITAa. Me IMMENSENESS <br />Coverage <br />Limit of Liability <br />' Premium'. - <br />Veh 1 <br />Veh 2 <br />A. Bodily Injury Liability <br />Includes $0.90 per vebids fraud fee <br />$ 100,000 each person <br />$ 300,000 each accident <br />$ <br />$ <br />$ <br />$ <br />B. Property Damage Liability <br />$ 100,000 each accident <br />$ <br />$ <br />$ <br />S <br />C. Medical Payments <br />$ each <br />person <br />$ <br />$ <br />S <br />S <br />Uninsured Motorist <br />D. Bodily Injury <br />S 100,000 .each person <br />S 300,000 each accident <br />$ <br />$ <br />S <br />$ <br />DAMAGE TO YOUR VEHICLE <br />Veh 1 1 Veh 2 <br />Actual Cash Value Less Dedumibla <br />Ded Ded. Ded. Ded. <br />E. Comprehensive s <br />$ -500. $ 500. <br />F. Collision <br />$ 500 $ Soo s' $ <br />$ <br />$ <br />$ <br />$ <br />Uninsured Motorist <br />DI. Property Damage <br />DEO WAIVE DED WAIVE <br />$ <br />$ <br />$ <br />$ <br />G. Roadside Assistance <br />$ 75 each disablement_ <br />Included <br />Included <br />Included <br />Included <br />Rental <br />H. Reimbursement <br />per day <br />I max <br />$ <br />$ <br />S <br />S <br />$ <br />$ <br />S <br />S <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 $ $ <br />Additional $ 0 $ 0 $ $ <br />Total $1,000 S1,000 $ $ <br />$ = <br />$ <br />$ <br />$ <br />Total Premium Per Vahicie <br />$ Is <br />S <br />S <br />H the installment bill plan is used, a service charge may <br />�ment(s)/Agreemem(s): Applicable: <br />(01/09) TCU511 CA j05/05) <br />EI) AS TO FO"Total Premium $ <br />Lauau - <br />city Attorney <br />Loss Payee ILP], Additional Insured (AH, Evidence of Insurance (EO Drivers Not Rated <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 />THE FOLLOWING FEE(S) MAY APPLY:.,.. �(Q_ <br />LATE: $5:00 PAYMENT RETURNED INSFI- $10.00_ 05/14/2009 <br />CANCEL: $50.00 INSTALLMENT HILL PLAN SERVICE CHARGE: $4.00 Vice 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 today) For Customer Care call 1-800-443-3100. <br />TCu41CA /04,091 21st Century fnsurance Company, 6301 Owensmouth Ave ;. Woodland Hids, CA 91367 <br />