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t 21st Century <br />insurance <br />Named Insured and Mailing Address <br />MICHAEL BRYANT <br />SANDRA BRYANT <br />28272 HARVEST VIEW LN <br />TRABUCO CANYON, CA 92679 <br />E-mail: SLBRYANT@COX.NET <br />r • <br />•' !IF -110-41111 • <br />AMEND - POLICY CHANGE <br />EFFECTIVE 08113116 <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: 360 66 90 <br />Policy Period: From 02/20/16 <br />To: 08120116 12:01 AM Standard Time <br />Vehicle(s) and Driver(s) <br />Limit of Liability <br />Premium <br />Von <br />ea <br />Make/Model <br />Vehicle ID Number <br />Use Vehicle Discounfs(Comments <br />Zip <br />Mlieage <br />1 <br />10 <br />CHEVROt.ET"TRAVE2SELTZ <br />1GNLRHED9AS108207 <br />P IVCD <br />92679 <br />9,111 , <br />2 <br />1 11 <br />TOYOTAPRUS <br />1 <br />JTDKN30UXBO261146 <br />P MCD <br />,B. Property DaMNe Liabili <br />92679 <br />9,111 <br />3 <br />' 12 <br />NISSAN ALTIMA25°25S <br />1N4AL2APXCN555232 <br />P MCD <br />92679 <br />5,111 <br />Veh <br />Rated Driver <br />-- <br />$100,000 each person <br />Years <br />Licensed <br />Tickets <br />Chargeable Accidents <br />Driver Discounts <br />4 <br />MICRAEL BRYANT <br />41 <br />0 <br />�- <br />GLD\SD6 <br />Veh 1 Veh 2 <br />Voh 3 <br />2 <br />SANDRA BRYANT <br />$ 152. a0 <br />35 <br />0 <br />Ded. <br />GDD\SD5 <br />E. Com rehen5tVe <br />5500_ _ $500 $500 1 <br />1 <br />JONATHAN BRYANT <br />$500 <br />01 <br />0 <br />$ 955.00 <br />MXD\GSD <br />3 <br />DAVID BRYANT <br />00 <br />0 <br />WAIVE <br />MXD <br />$ 5.00 <br />$ 7.00 <br />C V ERAUE IJ PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABiLI i Y AiRE 5HOWN FOR I HE COVERAGE <br />Coverage <br />Limit of Liability <br />Premium <br />Van <br />Veh2 <br />Ven3� <br />A. Bodily Injury <br />Liability <br />$100,00() each person <br />includes 30.66 <br />per vehicle fraud fee <br />_ $300, 000 each accident <br />$ 197.00 <br />$ 30.00 <br />$ 156.00 <br />,B. Property DaMNe Liabili <br />$100,000 each accident <br />_� <br />$ 227.00_ <br />$ 55_00 <br />$ 231.00 <br />C. Excess Medical Pa menu <br />$5 Oo0 each eersan <br />40.00 <br />q 3.00 <br />S 52.00 <br />Uninsured Motorist <br />$100,000 each person <br />D. BDdily In[urY _ <br />S3oo poo each accident <br />$ 68.00 <br />$ 24.00 <br />$ 89.00 <br />DAMAGE TO YOUR VEHICLE <br />Veh 1 Veh 2 <br />Voh 3 <br />$ 113.00 <br />$_32.00 <br />$ 152. a0 <br />Actual Cash Value Less Deductible <br />ped._ <br />Ded. <br />Ded. <br />E. Com rehen5tVe <br />5500_ _ $500 $500 1 <br />F. COIItSiOn <br />SSaQ 1 $SQO <br />$500 <br />S�572.Op <br />$_ 120.00 <br />$ 955.00 <br />Uninsured Motorist <br />D1.Pro rt Damage <br />DED WAIVE DED WAIVE ! DEC) <br />WAIVE <br />$ 7,00 <br />$ 5.00 <br />$ 7.00 <br />21 st Century <br />C. Roadside Assistance <br />RentsiT�Parday <br />$75 each disablement <br />$25S25 <br />$25 <br />Included <br />Included <br />- -- - <br />Included <br />-- <br />I -L Relmbursement max <br />$1So _ $750 �- <br />$150 <br />$ 28.00 <br />$ 21.00 <br />$ 28.00 <br />J. AdditionalE uipmant <br />The first $100 is automa0caliy, <br />Included $1,000 $1,060 <br />$1,000 <br />I AddlUnna€ <br />included with coverage Enr F. <br />�_.___Addlitana€ coverage isoptional <br />Tme, Si, OaO ^s 1, Qn0 <br />$l, oOQ <br />$ 0,00 <br />$ 0.00 <br />$ 0.00 <br />• <br />7akaI Pram tum Par Yahicte <br />S 1.,252.00 <br />_ <br />5 300.00 <br />$ 1'670.0O <br />If the installment bill pian Is used, a service charge may apply. -- <br />--- <br />Total Promtum <br />Endorsement(aYAgreement(s) Applicable: <br />TCE9ICA (Driver Exclusion) <br />Excluded Driver: <br />TCU -1 (04114) <br />TCU511CA (02/15) <br />JENNIFER LINN BRYANT <br />TCU531CA (02/12) <br />TCE751CA (01109) <br />GREGORY M BRYANT <br />i AU CWF91011 <br />MICHAEL F BRYANT <br />Loss Payee (LP), Additional Insured (At) <br />Drivers Not Rated <br />DAVID BRYAN <br />THE FOLLOWING FEE(S) MAY APPLY: 06/15116 <br />LATE: $5.00 PAYMENT RETURNED (NSF): $10.00 %1_/_Q� <br />CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE:$4.00 Cj�/�tgp(�pto M y�grre <br />auPOLK4-T'A N"F'"- rb <br />WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE THE POLI <br />THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. <br />Visit 219t.mm to make policy changes, pay your premium, and mora. Register online today! For Customer Care caCE00-24' 41!84 <br />TCU41CA (12/14) 21st Century Insurance Company, P.O. Bax 15510, Wilmington, DE 195865222 <br />�C�Q11 !" 7 BX. <br />