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Safeway Insurance Company41 <br /> P.O.BOX 5004,Monrovia, CA 91017-7104 Auto Application (cont.) M a <br /> ,p N <br /> Coverages/Premiums N <br /> 2013 CHEVROLET TRAVERSE LTZ AW Garaging Address: 2295 LIME AVE APT B,LONG BEACH,CA 90806 0i o <br /> VIN Registered State Odometer Reading Annual Mileage Mileage One Way N N <br /> 1 GNKVLKD8DJ255806 CA 10000 5 CO o <br /> Cost New Symbol Comprehensive/Collision Territory Multi Car Uehicfe Usage <br /> 26/20 H164 Yes Pleasure ix <br /> I'm Salvaged Restraint System ABS Brakes Anti-Theft Device <br /> 15 No No System Not Equipped ALARM ONLY <br /> Limits Premium <br /> Bodily Injury Liability $30,000 each person$60,000 each accident $ 112.00 <br /> Property Damage Liability $15,000 each accident $ 84.00 <br /> Comprehensive $1,000 deductible from actual cash value $ 58.00 <br /> Collision $1,000 deductible from actual cash value $ 191.00 <br /> Discounts:Anti-Theft,Good Driver and Multi-Car <br /> Total for 2013 CHEVROLET TRAVERSE LTZ AW $ 445.00 <br /> Subtotal Policy Premium $ 798.00 <br /> 0 Fees U <br /> Policy Fee $ 32.00 <br /> 12. Fraud Fee $ 1.76 a. <br /> Total Fees $ 33.76 <br /> d' Total Policy Premium $ 831.76 er <br /> r Additional Interest r <br /> to Only Lessees are accepted as Additional Interests N <br /> NVehicle and Additional Interest Loan Number N <br /> NPrior Insurance Coverage o <br /> N Prior Carrier and Years with Company Prior Policy Number and Expiration Date N <br /> 0 0 <br /> Z Z <br /> O O <br /> IW— H <br /> Z Z <br /> d: e2 <br /> a I1 <br /> W W <br /> ix De <br /> Z_ Z <br /> l <br /> O Q <br /> u_ <br /> ® O <br /> a. a <br /> ® p <br /> U U <br /> .o <br /> ••a <br /> aQ <br /> Rev.01/01/2025 Policy Package for 4340849-CA-PP-001 Return signed document N o <br /> 66 (Page 3 of 17) to your agent/broker R o <br /> aaii <br />