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121St Century <br />insurance <br />Named Insured and Mailing Address <br />Joe Larosa <br />Marie Larose, <br />9199 Poinsettia Ave <br />Fountain Valley, CA 92706 <br />Ilrlrrrrlrllrrrllirrrlrrlllrlrirrillrlrrllirrrirlrtirlrrirrlr <br />PERSONAL AUTO Renewal <br />POLICY DECLARATION EFFECTIVE 12115/2009 <br />rehicie(sI and DriverIS) - <br />lah Year - Mafte/Modal' Vehialo ID Nu bar Use <br />1 2004 RONDA PILOTLX 211KYF18134H566983 W MCD <br />2 2006 TOYOTA TUNDRA DOU OTBET341XGS552072 W MCO <br />Ye <br />5leh Rated Driver �--.Lice <br />1 Mario Larose <br />42 <br />2 Joe Larasa 43 <br />�Coverage <br />- <br />Limit of Llnbii <br />A. Bodily Injury Llability <br />S 100, 000 <br />each person <br />IachWas 80.90 Per vahide fraud loo <br />$ 300,000 <br />each aecider <br />D. Property Damage LlabElfty <br />$ 1a0, Oo0 <br />each accider <br />C. Medical Payments <br />$ _ <br />each person <br />Uninsured Motorist <br />S 10o, oo0 <br />each person <br />O Bodily Injury <br />$ 300,000 <br />each aecidei <br />DAMAGE TO YOUR VEHICLE <br />Veh 1 Voh 2 <br />Actual Cash Volua Leas Dadual'rele <br />tied. <br />Ded. _ E <br />Uninsured Motorist <br />D1. Property Damage DE <br />21st Century <br />G. SeCUfit Advanta e $ <br />Rental per day S <br />H. Reimbursement max $ <br />J. Additional Equipment it, <br />Tum (jest $1000 Is actomoticolly A <br />included with coverage E or F. <br />I,$ $ <br />$1,000 $1,000 $ <br />it S o $ o $ <br />$1,000 $1,000 S <br />PaOe 1 of 2 <br />Policy No: 3493189 <br />Policy Period: From: 1211512009 <br />To: 06/15/2010 12:01 AM Pacific Time <br />ehicle DlscountslComments _ Zf j Mileage <br />92706 8,170 <br />92706 7,449 <br />!cher, Chargeable Accidents <br />0 1 POICOLL coo <br />0 ODOjSUb <br />Discounts <br />if the installment bill plan is used, a service charge may apply. <br />L racer rrr .... ..— <br />Yfemttrm. <br />- <br />TCU -1 (01!09) TCU511CA (051051 <br />-Vch 1..Veh <br />2: <br />$ 155 <br />$ 78 <br />6 <br />S <br />23 <br />$ 103 <br />$ 85 <br />$ <br />$ <br />Veh 1 EI CLFY OF SANTA ANA PD <br />- - <br />Veh 1 - EI City of Anaheim PD <br />- - <br />Veh 2 LP Toyota Motor Credit Carp <br />- <br />$ 39 <br />$ 25 <br />$ <br />$ <br />Deft. <br />$ <br />$ 20_ <br />S 33 <br />S <br />$ <br />$ <br />$ at <br />$ Be <br />S <br />$ <br />S 5 <br />$ 5 <br />$ <br />$ <br />Included <br />included <br />Included_Ir <br />_ <br />S <br />S <br />s <br />$ <br />S <br />S <br />S <br />S <br />$ <br />_ <br />S - a03 <br />$ 314 <br />$__ - <br />S <br />if the installment bill plan is used, a service charge may apply. <br />L racer rrr .... ..— <br />FndorsemonL(s)lAgreement(sl Applicable: <br />AP/ D S TO FORM <br />TCU -1 (01!09) TCU511CA (051051 <br />TCU531CA 103109) - <br />e- <br />23 <br />Irl _ <br />Loss Payee (LP); Additional Insured (All, Evidence of in (Eq <br />Drivers Not Rated <br />- <br />y HOd$e <br />eputy ity Attorney <br />Veh 1 EI CLFY OF SANTA ANA PD <br />- - <br />Veh 1 - EI City of Anaheim PD <br />- - <br />Veh 2 LP Toyota Motor Credit Carp <br />- <br />I7HEFOLLOWNGFEEIS).MAY APPLY; . - - - <br />11/1312009 <br />LATE. - $5.00 PAYMENT RETUBPIED INSFI: +10.00 <br />i v ' �� <br />CANCEL: '550.00 INSTALL6dENT' BILL PLAN SER_VECE CHABGE: 54.00 i - Vi n I'reeldarrt <br />r",,,-, F. %THE I.]17:'.Y ilrggf:,F;'`'T <br />WHEN AT7ACHE0 7O lHt PERSONAL AUSD POLICY THI SE DFCLAnATION <br />n r' r!' arrOtt 1r <br />'1 �'€ CU NT 7t r 1r111 t t> a <br />-Y <br />('iri.iCf a PRn 19.11`ir `"7i ilb:9mfr Care(:P.Li r-E/UV i 3 .i?Ur). <br />z 1..1 c_:R to r ^� C-..-.'.� - F ... H11TJ^`. ..•,-..c. <br />I. .fi Hlf / C. {']411 <br />.1 <br />r. •a _?... r., 1. ,.i <br />