Laserfiche WebLink
ON <br />PERSONAL AUTO <br />21st Century POLICY DECLARATION <br />insurance <br />17 F <br />Named Insured and Mailing Address012'1ii LI: o <br />JOE LAROSA <br />MARIE LAROSA <br />9199 POINSETTIA AVE <br />FOUNTAIN VALLEY, CA 92708 <br />RENEWAL <br />and Driver(s) <br />EFFECTIVE 06/15/12 <br />�'\f <br />Make/Model <br />Vehicle iD Number <br />Account: <br />moi' <br />21ST CENTURY INSURANCE <br />Mile; <br />Customer Service Center: <br />04 <br />06 <br />21st CENTURY INSURANCE <br />2HKYF18134H568983 <br />5TBET341 X6S552072 <br />21ST CENTURY PLAZA <br />MCD <br />MCD <br />P.O. BOX 15510 <br />8,1 <br />7,4 <br />WILMINGTON, DE 19850-5510 <br />Rated Driver <br />Policy No: 8349 31 89 <br />Policy Period: From 06/15/12 <br />To: 12/15/12 12:01 AM Standard Time <br />Vehicle(s) <br />and Driver(s) <br />Veh <br />Year <br />Make/Model <br />Vehicle iD Number <br />Use <br />Vehicle Discounts/Comments <br />Zip <br />Mile; <br />1 <br />2 <br />04 <br />06 <br />HONDAPILOTLX <br />TOYOTA TUNDRA DOUBLE CAB SR <br />2HKYF18134H568983 <br />5TBET341 X6S552072 <br />W <br />W <br />MCD <br />MCD <br />92708 <br />92708 <br />8,1 <br />7,4 <br />Veh <br />Rated Driver <br />Years <br />Licensed <br />Tickets <br />Chargeable Accidents <br />Driver Discounts <br />2 <br />JOE LAROSA <br />45 <br />0 <br />GDD\SD5 <br />COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE <br />If the installment bill plan is used, a service charge may apply. <br />Total Premium <br />Endorsement(s)/Agreement(s) Applicable: <br />FPN-a 0711 TCU -1 (01/09)r <br />TCU511 CA (02/11) TCU531 CA (02/12) Aj TO FORM <br />AU CWF9 1011 d <br />Assistant City qu <br />torney <br />THE FOLLOWING FEE(S) MAY APPLY: � , /I/ jA 05/09/12 <br />-LATE: $5.00 PAYMENT RETURNED (NSF): $10.00 — <br />CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE.-$4.00Vice 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 21st.com to make policy changes, pay your premium, and more. Register online today! For Customer Care call 1-800-241-1188 <br />TCU41 CA (01110) 21 st Century insurance ComDanv. P.O. Box 15510. Wilminaton. DE 19886-5292 <br />Coverage <br />Limit of Liability <br />PremiumVeh <br />1 <br />Veh 2 <br />A. Bodily Injury Liability <br />includes $0.90 per vehicle fraud fee <br />$500,000 <br />$1, 000, 000 <br />each person <br />each accident <br />$ 148.00 <br />$ <br />96.00 <br />B. <br />Property Damage Liability <br />$100,000 <br />each accident <br />$ 84.00 <br />$ <br />94.00 <br />C. <br />Medical Payments <br />each person <br />D. <br />Uninsured Motorist <br />Bodily Injury <br />$500,000 <br />$1,000,000 <br />each person <br />each accident <br />$ 43.00 <br />$ <br />36.00 <br />DAMAGE TO YOUR VEHICLE <br />Veh 1 <br />Veh 2 <br />$ 14.00 <br />$ <br />31.00 <br />Actual Cash Value Less Deductible <br />Ded. Ded. <br />E. Comprehensive <br />$500 $500 <br />F. <br />Collision <br />$500 <br />$500 <br />$ 60.00 <br />$ <br />83.00 <br />D1. <br />Uninsured Motorist <br />Propeft Damage <br />DED WAIVE <br />DED WAIVE <br />$ 5.00 <br />$ <br />5.00 <br />G. <br />21 st Century <br />Roadside Assistance <br />$75 <br />each disablement <br />Included <br />Included <br />H. <br />Rental <br />Reimbursement <br />Per day <br />max <br />J. <br />Additional Equipment <br />The first $1000 is automatically <br />included with coverage E or F. <br />Additional coverage isoptional. <br />Included $1,000 $1,000 <br />Additional <br />Total $1,000 $1,000 <br />$ 0.00 <br />$ <br />0.00 <br />Total Premium Per Vehicle <br />$ 354.00 <br />$ <br />345.00 <br />If the installment bill plan is used, a service charge may apply. <br />Total Premium <br />Endorsement(s)/Agreement(s) Applicable: <br />FPN-a 0711 TCU -1 (01/09)r <br />TCU511 CA (02/11) TCU531 CA (02/12) Aj TO FORM <br />AU CWF9 1011 d <br />Assistant City qu <br />torney <br />THE FOLLOWING FEE(S) MAY APPLY: � , /I/ jA 05/09/12 <br />-LATE: $5.00 PAYMENT RETURNED (NSF): $10.00 — <br />CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE.-$4.00Vice 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 21st.com to make policy changes, pay your premium, and more. Register online today! For Customer Care call 1-800-241-1188 <br />TCU41 CA (01110) 21 st Century insurance ComDanv. P.O. Box 15510. Wilminaton. DE 19886-5292 <br />