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Safeway Insurance Company . . Fna cialSfenglhRnling <br /> P.O.BOX 5004 SAFEWAY INSURANCE ® v <br /> Monrovia,CA 91 0 1 7-71 04 �� (0 N <br /> F-N <br /> r N <br /> to_O <br /> Private Passenger Auto Application aco <br /> Policy Information <br /> Transaction Date: 02/20/2026 41.F- <br /> ce <br /> Carrier: Safeway Insurance Company <br /> NAIC: 12521 <br /> Phone:800-807-2339 <br /> Agent/Broker: ID#2129 <br /> A-MAX INSURANCE SERVICES <br /> 11330 FIRESTONE BLVD <br /> NORWALK CA 90650 <br /> Phone:866-603-9905 <br /> Applicant: DENNYS DIAZPADILLA <br /> 2295 LIME AVE APT B <br /> LONG BEACH,CA 90806 <br /> I- Cell Phone:714-809-8979 V <br /> Home Phone: <br /> 2 Bus Phone: 2 <br /> Effective Date/Time: 02/20/2026 10:40 AM ,expiring 08/20/2026 12:01 AM standard time 0_Tr Policy Term: 6 Month ti <br /> ni Pay Plan: Pay in Full et <br /> N <br /> r <br /> N <br /> Drivers uo <br /> c List all drivers(licensed or not)15 years of age and older. o <br /> Name(as it appears on license) Date of Birth Sex Marital Status Relationship CNII <br /> N DENNYS DIAZPADILLA 02/13/1966 Male Single Self N <br /> Years/Months Experience:44/0 Date of License: 02/13/1982 Driver Lic.No./State:Y2391856/CA CV <br /> Good Student: No Mature Driver: Good Driver: Yes o <br /> ZO Occupation: SALES Employer: O <br /> CI Driving History CI <br /> W Accidents and Minor Convictions--last 3 years;Major Convictions--last 10 years.(Note:Your driving record is <br /> � <br /> Z verified with state motor vehicle department(s)and other insurers.) <br /> Z Driver and Description Date Amount of Property Damage Z <br /> 2DENNYS DIAZPADILLA Points:0 0- <br /> LU At fault FINANCIAL RESPONSIBILITY ACCIDENT 12/07/2024 $0.00 Lu <br /> Coverages/Premiums <br /> Total Number of Vehicles in Household: 2 <br /> Z 2004 INFINITI FX35 Garaging Address: 2295 LIME AVE APT B, LONG BEACH, CA 90806 z <br /> 3 VIN Registered State Odometer Reading Annual Mileage Mileage One Way 3 <br /> JNRASO8U74X100633 CA 10000 5 fY <br /> O Cost New _Symbol Comprehensive/Collision Territory Mufti Car Vehicle Usage O <br /> Li. 17/17 H164 Yes Pleasure <br /> LI- <br /> O Type Salvaged Restraint System ARS.Brakes AntiTheftlDevice O <br /> 15 No No System Not Equipped ALARM ONLY } <br /> Limits Premium a <br /> O Bodily Injury Liability $30,000 each person$60,000 each accident $ 74.00 0 <br /> 0 Property Damage Liability $15,000 each accident $ 56.00 0 <br /> Comprehensive $1,000 deductible from actual cash value $ 48.00 <br /> Collision $1,000 deductible from actual cash value $ 175.00 <br /> Discounts:Anti-Theft,Good Driver and Multi-Car <br /> Total for 2004 INFINITI FX35 $ 353.00 <br /> APPROVED <br /> By Charlene R. Muro at 10:20 am, Mar 05, 2026 <br /> .to <br /> co O <br /> .d <br /> Rev.01/01/2025 Policy Package for 4340849-CA-PP-001 Return signed document di▪c <br /> 66 (Page 2 of 17) to your agent/broker o <br /> ¢va <br />