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C(21Nst Century <br />Insurance <br />PERSONAL AUTO <br />POLICY DECLARATION <br />Named Insured and Mailing Address <br />JOE LAROSA <br />MARIE LAROSA <br />9199 POINSETTIA AVE <br />FOUNTAIN VALLEY. CA 92708 <br />RENEWAL <br />EFFECTIVE 12/15/12 <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 12/15112 <br />To: 06/15/13 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 />Milee <br />1 <br />b4t <br />HONDA PILOT LX <br />2HKYF18134H568983 <br />W <br />MCD <br />92708 <br />8,1" <br />2 <br />06 <br />TOYOTA TUNDRA DOUBLE CAB SR <br />5TBET341X6S552072 <br />W <br />MCD <br />927081 <br />7,4, <br />Veh <br />Rated Driver <br />Years <br />Tickets <br />Chargeable Accidents <br />Driver Discounts <br />each person <br />licensed <br />2 <br />JOE LAROSA <br />46 <br />0 <br />$ <br />1 GDD\SD5 <br />1 <br />MARIE LAROSA <br />45 <br />0 <br />DAMAGE TO YOUR VEHICLE <br />1 GDD\SD5 <br />UOVEKAUlz 15 NKUVIULU VVMtKt A VKtMIUM ANU A LIMI I Ut- LIAMLI I Y AKt Jr'IUVVN t -UK I t1t UUVtKAUtz <br />If the installment bill plan is used, a service charge may apply. <br />Endorsement(s)/Agreement(s) Applicable: <br />FPN-a 0711 TCU -1 (10/12) <br />TCU511CA (05/12) TCU531CA (02/12) <br />AU CWF9 1011 <br />N <br />THE FOLLOWING FEE(S) MAY APPLY: <br />LATE: $5.00 PAYMENT RETURNED (NSF): $10.00 <br />CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE:$4.00 <br />Total Premium $ 699. <br />MOVED AS TO FORM <br />Laura A T' <br />11/08/12 <br />V �Vice )Preside Int <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 />TCU41CA (12/11) 21st Century Insurance Company, P.O. Box 15510, Wilmington, DE 19886-5292 <br />Coverage <br />Limit of Liability <br />Premium <br />Veh 1 <br />Veh 2 <br />A. Bodily Injury Liability <br />includes $0.90 per vehicle fraud fee <br />$500,000 <br />$1, o o 0 , o o o <br />each person <br />each accident <br />$ <br />148.00 <br />$ <br />96.00 <br />B. <br />Property.Damage Liability <br />$100,000 <br />each accident <br />$ <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 />$1,000,000 <br />each person <br />each accident <br />$ <br />43.00 <br />$ <br />36.00 <br />DAMAGE TO YOUR VEHICLE <br />Veh 1 <br />Veh 2 <br />$ <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 />$500 <br />$ <br />60.00 <br />$ <br />83.00 <br />D1. <br />Uninsured Motorist <br />Propgily Damage <br />DED WAIVE <br />DED WAIVE <br />$ <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 $1,000 <br />$ <br />0.00 <br />$ <br />0.00 <br />Total Premium Per Vehicle <br />$ <br />354.00 <br />$ <br />345.00 <br />If the installment bill plan is used, a service charge may apply. <br />Endorsement(s)/Agreement(s) Applicable: <br />FPN-a 0711 TCU -1 (10/12) <br />TCU511CA (05/12) TCU531CA (02/12) <br />AU CWF9 1011 <br />N <br />THE FOLLOWING FEE(S) MAY APPLY: <br />LATE: $5.00 PAYMENT RETURNED (NSF): $10.00 <br />CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE:$4.00 <br />Total Premium $ 699. <br />MOVED AS TO FORM <br />Laura A T' <br />11/08/12 <br />V �Vice )Preside Int <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 />TCU41CA (12/11) 21st Century Insurance Company, P.O. Box 15510, Wilmington, DE 19886-5292 <br />