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m Interinsurance Exchange of the Automobile Club <br />c Mailing Address: P.O. BOX 25001 SANTA ANA, CALIFORNIA 92799 -5001 <br />rcn� BINDER OF INSURANCE <br />Name and Address of Lienholder or Additional Insured Policy Number: CAA065514880 <br />PUBLIC WORKS AGENCY M -43 <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 92702 <br />NOTICE TO LIENHOLDER <br />IN THE EVENT OF CANCELLATION OF THIS <br />BINDER, THE EXCHANGE WILL GIVE THE <br />LIENHOLDER 10 DAYS' WRITTEN NOTICE OF <br />CANCELLATION. <br />Loan Number: <br />The Interinsurance Exchange of the Automobile Club hereby acknowledges itself bound to the named insured for the coverages specified in the <br />schedule subject to all the provisions of the Exchange's applicable policy form. The issuance of a policy to the named insured or, if a policy is in force, <br />the issuance of an endorsement covering the automobile, boat or trailer described herein shall void this binder. A pro rata premium charge computed for <br />the term of coverage in accordance with the current rates of the Exchange in effect at inception of the binder will be made unless such a policy or policy <br />endorsement is issued. This binder shall not be construed to afford cumulative insurance with any existing policy. <br />Name of Insured: ROYER, DAVID C AND MARY E <br />DESCRIPTION OF AUTOMOBILE, BOAT, OR TRAILER <br />Car No. <br />Year <br />Trade Name <br />Type of Body or Boat <br />Identification Number <br />2 <br />2005 <br />CHRY <br />CROSSFIRE <br />1C3AN69L05X053841 <br />AUTOMOBILE INSURANCE <br />LIMITS OF LIABILITY <br />" ✓" indicates coverage bound and afforded. <br />Car #2 <br />Car# <br />Bodily Injury Liability <br />$500 thousand dollars, each person <br />$500 thousand dollars, each occurrence <br />❑ <br />❑ <br />Property Damage Liability <br />$100 thousand dollars, each occurrence <br />❑ <br />❑ <br />Medical Payments <br />❑ <br />❑ <br />Underinsured /Uninsured Motorists <br />Not Less Than $15,000 each person /$30,000 each accident <br />❑ <br />❑ <br />Comprehensive (incl. Fire and Theft) <br />(a) Actual Cash Value less $100 deductible <br />❑ <br />❑ <br />❑ <br />Collision <br />0 Uninsured Deductible Waiver <br />(a) Actual Cash Value less $250 deductible <br />21 <br />❑ <br />❑ <br />❑ <br />Uninsured Collision <br />❑ <br />1 ❑ <br />WATERCRAFT INSURANCE (Boat) <br />LIMITS OF LIABILITY <br />"✓" indicates coverage bound and afforded. <br />Bodily Injury Liability and Property <br />Damage Liability <br />Thousand Dollars, each occurrence <br />Actual cash value not to exceed Limit of Liability of <br />$ less $ deductible <br />❑ <br />Physical Damage <br />Effective Date of Binder: 09/19/2013 12:01 A.M. Pacific Standard Time <br />This binder shall expire 30 days from the effective date or may be cancelled by the named insured at any time during such 30 -day period. The Exchange <br />may cancel this binder by mailing to the named insured at the address shown above written notice stating when, not less than 10 days thereafter, such <br />cancellation shall be effective. The mailing of such notice shall be sufficient proof of notice. <br />District Office: <br />By: <br />(Authorized Representative) <br />w51onviol <br />LC COA <br />091813 <br />ACSC Management Services, Inc. <br />APPROVED M- TOMM"CT <br />Laura SLltt S' •edy <br />Assistant City ttorney <br />