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PERSONAL AUTO <br />21St Century POLICY DECLARATION <br />insurance <br />Named Insured and Mailing Address 1011 NOV 30 PM 5: 37 <br />JOE LAROSA <br />MARIE LAROSA <br />9199 POINSETTIA AVE <br />FOUNTAIN VALLEY, CA 92708 <br />CITY C: ` :'�1A ANA <br />CLERK Ot COUNCIL <br />RENEWAL <br />EFFECTIVE 12/15/11 <br />Account: <br />21ST CENTURY INSURANCE <br />Customer Service Center: <br />21st CENTURY INSURANCE <br />21ST CENTURY PLAZA <br />P.O. BOX 15510 <br />WILMINGTON, DE 19850-5510 <br />Policy No: 8349 31 89 <br />Policy Period: From 12/15!11 <br />To. 06115112 12:01 AM Standard Time <br />Y'ehic[Q(s) and Driver{s) <br />Veh <br />1 <br />2 <br />-- _Make/Model Vehicle 10 Number Use Vehicle Discounts/Comments <br />04 HONDA PILOT LX ZIP Mlleac <br />2HKYF18134H568983 W Mff[ GD 927088,171 <br />06 TOYOTA TUNDRA DOUBLE CAB SR 5TBET341 X6,9552072 W MCMGD 92708 7,44! <br />Veh <br />2 <br />1 <br />;r Rated Driver Years Tickets Chargeable Accidents Driver Discounts <br />- Licensed <br />JOE LAROSA 45 0 SD5 <br />MARIE LAROSA 44 0 SD4 <br />COVERAGE IS PROVIDED WHERE <br />71 <br />A PREMIUM AND A LIMIT OF <br />LIABILITY ARE SHOWN <br />FOR THE COVERAGE <br />Premium <br />Coverage - <br />Limlk of Liability <br />A. Bodil InJJ'u Liability <br />includes per y <br />per vehicle fraud fee <br />B. Pro ert Dama a Liablii <br />C. Medical Payments <br />Uninsured Motorist <br />D. Bodily Injury <br />DAMAGE TO YOUR VEHICLE <br />$100, 000 each person <br />$300 000 each accident <br />$100 0o0 each accident <br />each person <br />$loo, 000 each person <br />$300,000 each accident <br />Veh i Veh 2 <br />Veh 1 <br />$ 143.00 <br />$ 9a.00 <br />$ 34.00 <br />$ 16.00 <br />Veh 2 <br />$ 79.00 <br />$ 93.00 <br />$ 26.00 <br />$ 31.00 <br />Actual Cash Value Less Deductible <br />Ded. Ded. <br />E. COm rehensive <br />F. Collision <br />Uninsured Motorist <br />$500 $500 <br />$500 $500 <br />!DED <br />$ 67.00 <br />$ 85.00 <br />Property Dam a <br />21st Century <br />FG.Security Advantage <br />Rental Per <br />H. Reimbursement max <br />wAlvs D8D WAIVE <br />$75 each disablement <br />$ 5.00 <br />$ 5.00 <br />Included <br />Included <br />J. Additional Equipment000 <br />The <br />$1, 000 <br />first $1000 is automatIncluded whitcoverage E <br />Q4iii�{ a is o t <br />If the ina&llmelfsplan Is used, a service <br />-, <br />000 $1, OooAdcRFtSnal <br />emium Per Vehicle <br />tf <br />charge may apply. <br />0.00 $ 0.00 <br />$ 359.00 S 319.00 <br />Total Premium $ <br />678.00 <br />Endo r3ment(s reement(s) Aaolicable: <br />FPN-a OP11 < TCU -1 (01/09)r APPR <br />TCU5142A (02111) TCU531 (01/10) OV ED AS <br />AU CTp FARM <br />V� 101 `1= <br />�U <br />Rated <br />1 F RISA L• JU <br />Assist;int City <br />Attorney i) <br />'THE FOLLOWING FEE(S) MAY APPLY:: V v l V <br />LATE $5:00- PAYMENT RETURNED (NSP): $10.80 �C'/,pL 11/08/11 <br />CANCEL: '$50.00` . INSTALLMENT BILL PLAN SERVICE CHARGE:$4.00 <br />Vice <br />WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE <br />nt THE ePOLICY AND REPRESENT <br />THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. <br />Visit 21st.com to make policy changes, pay your premium, and more_ Register online today! For Customer Care call 1-800-241-1188. <br />TCU41CA (01110) 21st Century Insurance Comnanv. P 0 Rnr issin wa„+i—t— nr ,000a g,)n, <br />