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Sentry'
IMPORTANT NOTICE
What You Should Know About Our Protection of Your Privacy
Protecting the personal information of the individuals we serve is a priority for Sentry Insurance. We collect, retain and
use personal information about individuals for the purpose of serving their insurance needs and providing services to
them.
This notice describes how we handle personal information of the individuals we serve. It is only for your information. No
action on your part is needed.
If you have questions regarding this notice, please write to Director of Privacy, 1800 North Point Drive, Stevens Point, WI
54481.
What kinds of information are collected and disclosed?
The types of information we may collect about you include:
Information you provide on applications or other forms, or in your verbal responses to our questions. This may
include identifying information such as name, address and information about your assets and income.
Information about your transactions with us including policies purchased and premium payment history.
Information we receive from a consumer reporting agency that indicates your credit worthiness and credit history.
Information we collect from you as part of the claims process.
We do not sell customer lists or any personal information regarding our customers.
We only disclose nonpublic personal information about customers or former customers to other affiliated or nonaffiliated
third parties as permitted or required by law. We may share personal financial information about you between affiliated
companies within the Sentry Insurance Group in order to make additional services available to you (e.g. auto insurance
customers may receive information about life insurance products, and vice versa). -
For those clients of Point Insurance Agency, LLC, Florists' Insurance Service Inc. and/or the Parker Stevens agencies,
these agencies may disclose your nonpublic personal information to nonaffiliated insurance companies as reasonably
necessary to provide you with insurance products and services.
How do we safeguard your privacy?
We maintain physical, electronic and procedural safeguards to protect your personal financial information.
We restrict access to nonpublic personal financial data to those associates who need to know that information in
order to provide products or services to you.
We communicate to associates in writing the importance of protecting confidential information.
We may amend our privacy policies at any time. If we do, we will inform you in writing.
This notice applies to each of the following companies. Companies may not be licensed in all states.
Sentry Insurance Company
Dairyland American Insurance Company
Dairyland County Mutual Insurance
Company of Texas
Dairyland Insurance Company
Dairyland National Insurance Company
Florists' Insurance Company
Florists' Insurance Services Inc.
Florists' Mutual Insurance Company
Middlesex Insurance Company
Parker Assurance Ltd.
Parker Centennial Assurance Company
Parker Services, L.L.C.
Parker Stevens Agency, L.L.C.
Parker Stevens Insurance Agency of
Massachusetts, Inc.
Patriot General Insurance Company
Peak Property and Casualty
Insurance Corporation
Point Insurance Agency, LLC
Point Insurance Company
Sentry Casualty Company
Sentry Equity Services, Inc.
Sentry Life Insurance Company
Sentry Life Insurance Company of
New York
Sentry Lloyds of Texas
Sentry Select Insurance Company
Viking Insurance Company of
Wisconsin
01 r; 62s0-12220
Page 2 of 2
COAST AUTO INS #6
401 E 10TH ST STE 2
GILROY CA 95020-6624
September 24, 2021
Named Insured(s)
RODRIGUEZMEJIA, MARVIN A
7351 ROSANNA ST
GI LROY CA 95020-6141
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Policy Number: 11407299563
Dear MARVIN,
Phone: 1-408-842-1990
Agency Code: 6091
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Unfortunately, your policy does not qualify for the Good Driver discount.
My.Dairylandlnsurance.com
To qualify, specific criteria must be met as mandated by California law. In general, the requirements are as
follows:
A driver must have a valid driver's license for the past three years
Cannot have more than one Department of Motor Vehicle violation point within the past three years
Cannot have certain types of driving under the influence convictions within the past 10 years
Your policy does not qualify for the discount for the following reason(s):
RodriguezMejia, Marvin, A has not had a valid drivers license for the last three years.
We appreciate your business.
Nothing contained in this notice changes the effective dates listed on any outstanding bill, nonrenewal notice, expiration notice, or
cancellation notice sent to you.
' CA5039-0517
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3 00018 0001168 21268-1 N A 0 0027020044362439658495020614151
Page 1 of 1
COAST AUTO INS #6
VIKING INSURANCE COMPANY OF WISCONSIN
401 E 10TH ST STE 2
GILROY CA 95020-6624
Named Insured(s)
RODRIGUEZMEJIA, MARVIN A
7351 ROSANNA ST
GILROY CA 95020-6141
III��I�IIIIII�I���II�II�IIIIII��II�II'IIII����III�1�Illlllllllll�
Premium and Coverage Information
Phone: 1-408-842-1990 Agency Code: 6091 Vairq"M
My.Dairylandlnsurance.com
DECLARATIONS PAGE
Policy Number 11407299563
Policy Term 09/24/2021 to 03/24/2022
Transaction 09/24/2021 12:01 a.m. Local Time
Effective Policy effective at time of application or
when coverage is bound, whichever is later.
Transaction New Business
Type
This Is Not a Bill. Retain for your records.
:.::::::.:•:::.....•.•:..... •:::.•:.:•::::.:•::::::. ,..:::.•:::...:.:::...:.::::.:..:...........:.:::.:..:......... a...:..:.:::::::,:.:::..::::..::...•.•::..:.:•::.•::......:::::::.:• .:.:.•:.:•:...• :.
:1ehicle .Level Covera es :::::::::.::.,,•: .:.•:.:•:.:• :•:.:::•::.•:: ,:::::.Lurnts•:.:•:.•.•.:•:.: _ :: :.., .... :.::.:•:.•.•:.•.•::.•::.:•::::.::::.::::.•:::.:..:.•::.,•:.•.•: _:.:...::
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...,.......................:..........:................1......:............. ........ ........_ :.....,......:..:.._..:: :.__.....:.....
Rated Driver
Bodily Injury Liability S15,000 Each Person/530,000 Each accident $101.52
Property Damage Liability $10,000 Each accident $156.96
Uninsured Motorist Bodily Injury Rejected
Underinsured Motorist Bodily Injury Rejected
Uninsured Motorist Property Damage Rejected
Mexico Limited Coverage Included
Subtotal Premium By Vehicle $258.48
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Premium Subtotal $258.48
CA Fraud Assessment $0.84
Total Policy Premium S259.32
Discount Information: None
Surcharge Information: None
Vehicle Information
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1 2014 Volkswagen JETTA S 3VW2K7AJ2EM300823 N 95020 43 Pleasure 5,000
Driver Information
.......................................
................ ............................................
. ................afe of �rrth `:Gi?iideM:.
•• •::FinancilFs obtrm........ nsi:e:Sp1 RODRIGUEZMEJIA, MARVIN A 02/01/1982 M S
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DECA-CA-0517 Process Date: 09/24/2021 - 04:05 PM Central Time per Stevens Point, WI Pagel of 2
5 00018 0001168 21266-1 N A 0 0027020044362439658495020614151
Driving Experience
Date first licensed in U.S./Canada
Dry # 1 N/A
Date first licensed outside of U.S./Canada
Dry # 1 02/01 /1998
Excluded Driver Information: None
Non -Driver Information: None
Accident and Violation Information: None
Lienholder/Additional Insured/Additional Interest Information: None
Policy Forms
The following policy forms and endorsements apply to your policy.
CAM 101-0121 CAUM-0517 CAUMPD-0517
MCEI-CA-1117 PAP1-1213 PPA-CA-1120
Important Messages
This policy is effective on the date shown on the face of these declarations. These declarations form a part of the policy.
Access your policy documents online at My.Dairylandlnsurance.com.
Policy Restriction: IF this policy provides coverage that exceeds the limits required by the applicable Financial
Responsibility laws, then such excess coverage shall not apply to the operation, maintenance or use of your insured car
by any person other than "you", but this limitation shall not apply to liability incurred by "you". Refer to definition of "you"
in the policy.
Your automobile premium rates are affected by each ticket and chargeable accident on the driving records of the drivers
of your insured auto. Contact your producer for additional details or questions. jo
DECA-CA-0517 Process Date: 09/24/2021 - 04:05 PM Central Time per Stevens Point, WI Page 2 of 2
Viking Insurance Company of Wisconsin e
My.Dairylandlnsurance.com
IN CASE OF AN ACCIDENT, PLEASE CALL 1-800-334-0090.
CLAIMS CAN BE REPORTED 24 HOURS A DAY.
Important: This insurance policy is a legal contract between you and us.
Read Your Policy Carefully. This index of policy provisions provides a brief outline of some of the important features of
your policy. But, the index is not the insurance contract. Only the actual policy provisions will dictate. The policy sets
forth in detail the rights and obligations of both you and us.
PERSONAL AUTO POLICY.
Agreement.
What To Do In Case Of A Car Accident or Loss.
Notice of Car Accident or Loss.
Other Duties.
Definitions Used Throughout This Policy.
Part 1- Liability Coverage.
Additional Definitions Used in This Part Only.
Additional Payments.
Exclusions.
Conformity with Financial Responsibility Laws.
Out of State Insurance.
Limits of Liability.
Other Insurance.
Part 11- Medical Payments Coverage.
Additional Definitions Used In This Part Only.
Exclusions.
Limits of Liability.
Other Insurance.
Our Rights to Recover Payment.
Part III - Uninsured Motorists Coverage.
Additional Definitions Used in This Part Only.
Exclusions.
Limits of Liability.
Other Insurance.
Arbitration.
Part IV - Car Damage Coverage.
Additional Definitions Used in This Part Only.
Your Deductible.
Settlement of Loss.
Appraisal.
Transportation Expenses.
Exclusions.
Limits of Liability.
No Benefit to Bailee.
Other Insurance.
Part V - General Provisions.
Territory.
Changes.
Two or More Cars Insured.
Lawsuit Against Us.
Our Recovery Rights.
Assignment.
Bankruptcy.
Electronic Signatures.
Out of State Insurance.
Joint and Individual Interests.
Renewal of This Policy.
Cancellation or Nonrenewal of This Policy.
Misrepresentations.
Notice of Our Information Practices.
AGREEMENT.
In return for your premium payment, we will insure you for the coverages up to the limits of liability for which a premium
is shown on your Declarations Page. However, acceptance by us of premium payments submitted by you or on your
behalf does not, in and of itself, satisfy coverage conditions. This agreement is subject to the terms and conditions of
this policy. This insurance applies only to car accidents and losses which happen while this policy is in force. This
policy is issued by us in reliance upon the statements which you made in your application for insurance. We may also
ask you for updated information after the policy has issued. We rely upon you to provide us with accurate information.
This policy, your application (which is made a part of this policy as if attached), and your Declarations Page include all
the agreements between you and us relating to this insurance. If you have made any misrepresentations in your
application or when subsequently asked, this policy may not provide any coverage.
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01 PAP1-1213
7 00018 0001168 21268-1 N A 0 0027020044362439658495020614151
Page 1 of 13
WHAT TO DO IN CASE OF A CAR ACCIDENT OR LOSS.
Notice of Car Accident or Loss.
In the event of a car accident or loss, prompt notice must
be given to us. This must include the time, place and facts
of the car accident or loss. Your name, address, the best
.way to contact you and any involved persons and
witnesses must be provided. The information which you
give to us must be truthful and accurate.
Other Duties.
Any person claiming any coverage under this policy must:
(1) Cooperate and assist us in any matter regarding a
claim or lawsuit.
(2) Promptly send us any legal or other papers relating to
a clairn or lawsuit.
(3) Submit to physical exams at our expense by doctors
we select. This must be as often as we reasonably
require.
(4) Authorize us to obtain medical, wage and other
records.
(5) Submit separately to recorded statements and
exams under oath. Provide sworn statements. This
must be done as often as we reasonably require.
(6) Avoid making any voluntary payments except at your
own expense. Avoid making any obligation or incurring
any expense.
(7) Promptly complete and return any forms we send to
you.
(8) Permit us to retrieve data from the event data recorder
of the vehicle involved in the car accident.
(9) Promptly notify the police of the accident if a
hit-and-run driver is involved.
(10)Take reasonable steps after loss to protect your
insured car and its equipment from further loss. We
will pay reasonable expenses incurred in providing
that protection. Any additional loss because of your
failure to take reasonable steps to protect your
insured car will not be covered.
(11) Promptly report any theft or vandalism of your
insured car or its equipment to the police.
(12) Allow us to inspect and appraise the damage to your
insured car before its repair or disposal.
Failure to perform or comply with any of these duties may
result in the refusal of coverage, protection or a reduced
loss payment.
DEFINITIONS USED THROUGHOUT THIS POLICY.
(1) "We", "us" and "our" mean the Company shown on
your Declarations Page providing this insurance.
(2) "You" and "your" mean the person(s) shown as the
Named Insured on your Declarations Page. You and
your also means that person's spouse if residing in
the same household.
(3) "Relative" means a person living in your household.
This person must be related to you by blood, marriage
or adoption. Relative includes a ward, foster child or a
minor under your guardianship who lives in your
household. Your unmarried dependent children living
temporarily away from home qualify as a relative only
if they intend to continue to live in your household.
Any relative who is of legal driving age or older must
be listed on the application or endorsed on the policy.
This must occur prior to a car accident or loss.
(4) "Regular operator" means any person of legal driving
age or older and a resident of your household.
Regular operator also means any person who drives
your insured car while it is furnished or available for
their regular use.
(5) "Bodily injury" means bodily harm, or sickness,
disease or death.
(6) "Property damage" means damage to or destruction
of real or tangible personal property. This includes loss
of that property's use. It does not include
electronically stored information or other intangible
property.
(7) "Car" means a four -wheeled land motor vehicle,
licensed for use on public roads and not used for
commercial purposes, which is:
(A) Of the private passenger sedan, station wagon,
minivan or jeep type, with a gross vehicle weight
rating (GVWR) of 10,000 pounds or less; or
(B) Of the pickup, 6-wheel dually, sport utility, van or
panel truck type, with a gross vehicle weight rating
(GVWR) of 14,000 pounds or less.
(8) "Your insured car" means all of the following.
(A) Any car described on your Declarations Page, for
which a premium charge is shown.
(B) Any car that permanently replaces a car
described on your Declarations Page during the
policy period. With respect to coverage under
Parts I, II and III of this policy, the replacement car
will be afforded the same coverage as the car it
replaces. Coverage will apply as of the date you
acquire the car, but only if you ask us to insure it
PAP1-1213 Page 2 of 13
RT,
within fourteen (14) days of its acquisition.
Coverage under Part IV and other optional
coverages will apply to the replacement car as of
the date you acquire the car only if you expressly
ask for it within three (3) days of its acquisition.
We must also agree to provide the coverage
before it will apply. In all other cases, any
coverage you request will apply no earlier than the
date and time you contact us to request it and we
agree.
(C) Any additional car you acquire ownership of
during the policy period that does not
permanently replace a car described on your
Declarations Page, but only if we insure all other
cars you own. With respect to coverage under
Parts I, II and III of this policy, the additional car
will be afforded the same coverage as any other
car described on your Declarations Page.
Coverage will apply as of the date you acquire the
car, but only if you ask us within fourteen (14)
days of its acquisition. Coverage under Part IV
and other optional coverages will apply to the
additional car as of the date you acquire the car
only if you expressly ask for it within three (3) days
of its acquisition. We must also agree to provide
the coverage before it will apply. In all other cases,
any coverage you request will apply no earlier
than the date and time you contact us to request
it and we agree.
(D) Any car not owned by you while being used
temporarily by you or a relative. The use must be
with the owner's permission. The car must be a
substitute for a vehicle described on your
Declarations Page which is withdrawn from normal
use due to breakdown, repair, servicing, loss or
destruction. This provision applies only to
coverages provided in Parts I, II and III of this
policy.
A car leased to a person under a written agreement for a
constant period of at least six (6) months shall be deemed
to be owned by that person.
(9) "Motor vehicle" means a land motor vehicle, but
does not mean a vehicle as described below.
(A) Operated on rails.
(B) Operated on crawler -treads.
(C) A farm type tractor or equipment designed for use
mainly off public roads when not used on public
roads.
(D) An all -terrain or other recreational vehicle type, not
licensed or designed for use on public roads.
(E) Being used as a residence.
(F) Being used as a premise.
(10) "Auto Business" means the business of selling,
repairing, servicing, storing, or parking cars. It also
means the business of transporting, delivering,
testing, road testing or repossessing cars.
(11) "Occupying" means in, getting in, or getting out of.
(12) "Car Accident" means an unexpected and
unintended event that causes bodily injury or
property damage. It must have arisen out of the
ownership, upkeep, or use of a car or motor vehicle.
(13) "Loss"means direct, sudden and accidental damage
or theft of your insured car or its covered equipment.
(14) "State" means the District of Columbia, and any
state, territory or possession of the United States.
(15) "Misrepresent" or "Misrepresentation" means
providing information to us that is known by you to be
false, misleading or fraudulent. This could be
presented to us during the application for coverage, or
during the policy period. It must affect either the
eligibility for coverage and/or the premium that is
charged. Concealing information relevant to the
application, or maintenance of coverage, is also
misrepresentation.
PART I - LIABILITY COVERAGE.
This coverage applies only if a premium is shown for it on
your Declarations Page.
We will pay damages for which any insured person is
legally liable because of bodily injury and/or property
damage caused by a car accident. The car accident
must have arisen out of the ownership, upkeep or use of a
car. We will settle any claim or defend any lawsuit which
is payable under the policy as we deem appropriate.
Additional Definitions Used in This Part Only.
As used in this Part, these definitions apply.
(1) "Insured person" or "insured persons" means all of
the following.
(A) You.
(B) A relative.
We have no duty to defend any suit or settle any claim for (C) Any person using your insured car.
bodily injury or property damage not covered under this No one is considered an insured person if they use a car
policy. without the permission or outside the scope of the
Our duty to settle or defend ends when our limit of liability permission of the owner.
for this coverage has been tendered or paid. None of the following are insured persons for this
coverage.
PAP1-1213 Page 3 of 13
9 00018 0001168 21268-1 N A 0 0027020044362439658495020614151
(A)* The United States (U.S.) Government. (3)
(B) Any other government or civil authority.
(C) Any person operating a motor vehicle as an
employee of the U.S. Government, when the
provisions of the Federal Tort Claims Act apply.
(2) "Contamination" means any unclean, unsafe, (4)
damaging, injurious, or unhealthy condition. The
condition must have arisen from pollutants, whether
permanent or transient.
(3) "Pollutants" means smoke, vapors, soot, fumes,
acids, sounds, alkalis, chemicals liquids, solids, gases,
thermal substances. It includes any other irritants and
impurities.
Additional Payments.
We will pay, in addition to our limit of liability, all of the
following.
(1) Costs we incur when settling any claim or in the
defense of any lawsuit. This does not include awards
to the plaintiff.
(2) Interest on damages awarded in any lawsuit we
defend for the portion of damages that does not
exceed our limit of liability. The interest must accrue
after entry of judgment and before we have paid. Our
offer to pay will also stop interest accrual. Interest will
stop accruing if we deposit in court that portion of the
judgment which is not more than our limit of liability.
(3) Premiums on bonds required in any lawsuit we
defend. We will not pay the premium for a bond that is
more than our limit of liability. We have no duty to
apply for or furnish bonds.
(4) Up to $200 a day of lost wages when we ask an
insured person to attend trials or hearings.
(5) Any other reasonable expenses incurred by an
insured person at our specific request.
Exclusions.
Coverage and our duty to defend does not apply to any of
the following.
(1) Bodily injury or property damage arising out of the
ownership, upkeep or use of any vehicle when used to
carry persons or property for compensation or a fee.
This includes, but is not limited to, delivery of
newspapers, magazines, food, or any other products.
This exclusion does not apply to shared -expense car
pools.
(2) Bodily injury or property damage caused with intent
by, or at the direction of, an insured person. This
exclusion applies when an insured person commits
an act which is reasonably certain to cause harm or
damage. This exclusion applies even if the actual
result is different than that which was intended or
expected.
Bodily injury or property damage that results from
nuclear reactions, radiation or fallout. Bodily injury or
property damage with respect to which any person is
insured under nuclear energy liability insurance is also
excluded, even if the limits of that insurance are
exhausted.
Bodily injury to an employee or a fellow employee of
an insured person that arises during the course of
employment. This exclusion does not apply to bodily
injury to a domestic employee unless workers'
compensation benefits are required or available for
that employee.
(5) Bodily injury or property damage arising out of the
ownership, upkeep, or use of any vehicle, including
your insured car, when used for any business
purpose. This exclusion does not apply to:
(i) Use of your insured car by you or a relative for
farming or ranching.
(ii) The use of your insured car by you for auto
business operations.
(iii) Business use that has been disclosed to and
accepted by us.
(iv) Business use that is infrequent and not otherwise
excluded under this policy.
(6) Damage to property owned by, rented to, being
transported by, used by, or in the charge of an
insured person. This exclusion does not apply to
damage to a private residence or garage rented to you
or a relative. A motor vehicle operated by an insured
person is considered to be property in the charge of
an insured person.
(7) Bodily injury or property damage assumed by an
insured person under any contract or agreement.
(8) Bodily injury or property damage arising out of the
ownership, upkeep or use of your insured car while it
is being leased or rented to others.
(9) Bodily injury or property damage arising out of the
ownership, upkeep, or use of any vehicle other than
your insured car. This exclusion applies only if the
vehicle is owned by, or furnished or available for
regular use by you or a relative.
(10) Bodily injury to you or a relative.
(11) Bodily injury or property damage caused while any
vehicle is used in, or preparing for, any racing,
speeding, stunt, performance or demolition activity.
This exclusion applies whether or not such activity is
prearranged or organized.
(12) Bodily injury arising out of or related to pollutants
and/or contamination.
(13) Bodily injury or property damage arising out of the
loading or unloading of any car. This exclusion does
not apply to you or a relative.
PAP1-1213 Page 4 of 13
(14) Bodily injury or property damage arising out of the
use of a vehicle for snow removal.
(15) Bodily injury or property damage arising out of the
ownership, upkeep or use of any car while it is being
used in connection with any type of personal vehicle
sharing program.
(16) Bodily injury or property damage arising out of the
use of a vehicle in any illegal trade or transportation.
(17) Bodily injury or property damage arising out of the
use of a vehicle in the commission of a non -vehicular
felony. This includes the attempt to elude arrest by a
law enforcement official.
(18) Punitive or exemplary damages.
Conformity with Financial Responsibility Laws.
If we certify this policy as proof of compliance under any
financial responsibility law, it will comply with that law to
the extent of the coverage required by the law. You must
repay us if we have to make a payment that we would not
have had to make if this policy were not certified.
Out of State Insurance.
If an insured person must comply with the financial
responsibility law of another state, this policy will provide
any broader coverage. This provision also applies to the
compulsory insurance law or similar laws of another state.
The insured person must be subject to those laws
because of the ownership, upkeep or use of your insured
car in that state. Any broader coverage so afforded shall
be reduced to the extent that other liability coverage
applies. No person may, in any event, collect more than
once for the same elements of loss.
Limits of Liability.
Subject to the following terms, the limits of liability shown
on your Declarations Page are the most we will pay in
damages for any one car accident.
(1) The bodily injury liability limit for "each person" is the
maximum limit for all claims by all persons for
damages from bodily injury to one person. This limit
includes all family member claims, claims for care and
loss of services, loss of companionship, loss of
society and loss of consortium.
(2) Subject to the bodily injury liability limit for "each
person", the bodily injury liability limit for "each
accident" is the total limit for all claims for damages
from bodily injury to two or more persons in any one
car accident. This limit includes all family member
claims, claims for care and loss of services, loss of
companionship, loss of society and loss of
consortium.
(3) The property damage liability limit for "each accident"
is the limit for all claims for damages, by all persons to
property in any one car accident. These damages
may be direct or indirect.
We will pay no more than these limits despite of any of the
following.
(1) The number of vehicles described or premiums shown
on your Declarations Page.
(2) The number of insured persons.
(3) The number of claims made or lawsuits filed.
(4) The number of persons making claims.
(5) The number of policies issued by us.
(6) The number of vehicles involved in the car accident.
Any amount payable to any person under this part will be
reduced by any amount paid or payable to that person
under Part II or Part Ill.
No one will be entitled to duplicate payments under this
policy for the same elements of damages.
If this policy provides coverage that exceeds the limits
required by the applicable Financial Responsibility laws,
then such excess coverage shall not apply to the
operation, upkeep, or use of your insured car by any
person other than you or a relative. This limitation shall
not apply to liability incurred by you or a relative.
Other Insurance.
If there is other applicable coverage on a loss covered by
this Part, we will pay only our share of the damages. Our
share is the ratio that the limits of liability bear to the total
of all applicable limits.
For coverage afforded under this Part for a car you do not
own, this coverage is excess over any other applicable
insurance.
Coverage under this Part will be primary for the use of
your insured car by you or any rated driver listed on your
Declarations Page. For any other person using your
insured car, this coverage will be excess over any other
applicable insurance.
PART II - MEDICAL PAYMENTS COVERAGE.
This coverage applies only if a premium is shown for it on Any rights to payment under this Part no longer exist to
your Declarations Page. the extent an insured person recovers payment from the
This coverage does not apply at all if there is any Personal responsible party.
Injury Protection Coverage in effect at the time of the car We will pay the usual and customary charge for
accident. reasonable and necessary expenses incurred within one
year from the date of car accident. The expenses must
be for medical and funeral services because of bodily
Udi
rem
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personal vehicle sharing program.
injury sustained by an insured person and caused by a
car accident.
Reasonable medical expenses do not include expenses
described as follows.
(1) For treatment, services, products or procedures that
are untried, for research, or not primarily designed to
serve a medical purpose, or are not commonly
recognized throughout the medical profession and
within the United States as appropriate treatment of
bodily injury;
(2) Incurred for the use of thermography or other related
procedures of a similar nature.
(3) Incurred for the use of acupuncture or other related
procedures of a similar nature.
(4) Incurred for the purchase or rental of equipment not
primarily designed to serve a medical purpose.
Additional Definitions Used In This Part Only.
As used in this part:
(1) "Insured person" or "insured persons" means any of
the following.
(A) You or a relative while occupying your insured
car.
(B) You or a relative as a pedestrian when struck by
a motor vehicle.
(C) Any other person while occupying your insured
car while the car is being used by you or another
person with your permission.
No one is considered an insured person if they use a
car without the permission or outside the scope of
the permission of the owner.
(2) "Usual and customary charge" means an amount
which we, determine as a customary charge for
services in the region in which the service is rendered.
We may determine this charge through the use of
independent sources of our choice.
Exclusions.
This coverage does not apply to bodily injury described
as follows.
(1) Sustained while occupying your insured car when
used to carry persons or property for compensation or
a fee. This includes but is not limited to delivery of
newspapers, magazines, food, or any other product.
This exclusion does not apply to shared -expense car
pools.
(2) Sustained while occupying any vehicle being used as
a residence or premises.
(3) Sustained while occupying a motor vehicle with less
than four wheels.
(5) Sustained while occupying or when struck by any
vehicle, other than your insured car, which is owned
by or furnished or available for regular use by you.
(6) Sustained while your insured car is being leased or
rented to others.
(7) Arising out of the ownership, upkeep, or use of any
vehicle including your insured car, when used for any
business purpose. This exclusion does not apply to:
(i) Use of your insured car by you or a relative for
farming or ranching.
(ii) The use of your insured car by you for auto
business operations.
(iii) Business use that has been disclosed to, and
accepted by, us.
(iv) Business use that is infrequent and not otherwise
excluded under this policy.
(8) Occurring during the course of employment if
benefits are payable under a workers` compensation
law, disability benefits or other similar laws. This
exclusion also applies when benefits are required to
be provided under similar laws.
(9) Caused by, or as an effect of, war (declared or
undeclared), civil war, insurrection, riot, acts of
terrorism, rebellion, or revolution. This exclusion also
applies to damages caused by nuclear reaction,
radiation or radioactive contamination.
(10) Sustained while occupying any vehicle being used in
or to prepare for any racing, speed, stunt,
performance or demolition activity, whether or not
such activity is prearranged or organized.
(11) Intentionally caused by or at the direction of an
insured person. This exclusion applies when an
insured person commits an act which is, to a large
extent, certain to cause harm or damage. This
exclusion applies even if the actual result is different
than that which was intended or expected.
(12) Caused when a vehicle is being used in the
commission of a non -vehicular felony or while
attempting to elude arrest by a law enforcement
official.
(13) Sustained while your insured car is being operated
by a regular operator who was not reported to us.
The regular operator must be reported on the original
application for insurance or otherwise disclosed to us
and listed on your Declarations Page before the car
accident.
(14) Caused when a vehicle is being used in any illegal
trade or transportation.
Limits of Liability.
(4) Arising out of the ownership, upkeep or use of any car We will pay no more than the limits of liability shown for
while it is being used in connection with any type of this coverage on your Declarations Page for each person
PAP1-1213 Page 6 of 13
injured in any one car accident despite any of the No one will be entitled to duplicate payments under this
following. policy for the same elements of damages.
(1) The number of vehicles described or premiums Other Insurance.
shown on your Declarations Page.
This Medical Payments Coverage is excess over any other
(2) The number of insured persons. applicable insurance.
(3) The number of claims made or lawsuits filed.
(4) The number of persons making a claim.
(5) The number of policies issued by us.
(6) The number of vehicles involved in the car accident.
Any amount payable to any person under this part will be
reduced by any amount paid or payable to that person for
the same expense under Part I or Part Ill.
Our Rights To Recover Payment.
If we make payment under this Part, we shall be entitled,
to the extent of such payment, to the proceeds of any
settlement or judgment recovered from, or on behalf of,
any responsible party.
PART III - UNINSURED MOTORISTS COVERAGE.
This coverage applies only if there is a premium shown for
it on your Declarations Page.
We will pay damages for bodily injury which an insured
person is legally entitled to recover from the owner or
operator of an uninsured motor vehicle. The bodily
injury must be caused by a car accident and result from
the ownership, upkeep or use of an uninsured motor
vehicle.
Any judgment for damages arising out of a suit brought
without our consent is not binding on us.
Additional Definitions Used in This Part Only.
As used in this Part
(1) "Insured Person" means any of the following.
(A) You.
(B) A relative.
(C) Any other person occupying your insured car
with the permission of you or a relative.
(D) Any person for damages that person is entitled to
recover because of bodily injury to you, a relative
or another occupant of your insured car.
No person shall be considered an insured person if that
person uses a motor vehicle without permission of the
owner.
(2) "Uninsured motor vehicle" means a motor vehicle
which is:
(A) Not insured by a bodily injury liability bond or
policy or that does not have liability limits
complying with the financial responsibility law of
the policy state.
(ii) A relative.
(iii) A vehicle which you or a relative are
occupying.
(iv) Your insured car.
There must be actual physical contact with the
hit-and-run vehicle.
(C) Insured by a bodily injury liability bond or policy
at the time of the accident whose insurer is or
becomes insolvent or denies coverage.
"Uninsured motor vehicle" does not mean a vehicle as
described below.
(A) Owned by, furnished or available for your regular
use or a relative's regular use.
(B) Owned or operated by a self -insurer. This must be
within the meaning of any motor vehicle financial
responsibility law, motor carrier law or any similar
law. This definition does not apply if that
self -insurer is or becomes insolvent.
(C) Owned by a governmental unit or agency.
(D) Designed mainly for use off public roads, while not
on public roads.
(E) Operated on rails or crawler treads.
(F) While used as a residence or premises.
Exclusions.
This coverage does not apply to bodily injury sustained
by an insured person described by any of the following.
(1) While occupying a motor vehicle owned by you or a
relative which is not your insured car.
(B) A hit-and-run vehicle whose operator or owner is (2) When struck by a motor vehicle owned by you or a
unknown. This vehicle must strike any of the relative.
following.
(3) While occupying a motor vehicle with less than four
(i) You. wheels.
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(4) If the injured person or the legal representative of that
person agrees to any settlement without our written
consent.
(5) While occupying your insured car when used to
carry persons or property for compensation or a fee.
This includes, but is not limited to, delivery of
newspapers, magazines, food, or any other products.
This exclusion does not apply to shared -expense car
pools.
(6) Arising out of the ownership, upkeep, or use of any
vehicle including your insured car, when used for any
business purpose. This exclusion does not apply to:
@ Use of your insured car by you or a relative for
farming or ranching.
(ii) The use of your insured car by you for auto
business operations.
(iii) Business use that has been disclosed to, and
accepted by, us.
(iv) Business use that is infrequent and not otherwise
excluded under this policy.
(7) While any vehicle is being used in or to prepare for any
racing, speed, stunt, performance, or demolition
activity. This exclusion applies whether or not such
activity is prearranged or organized.
(8) While your insured car is being operated by a regular
operator who was not reported to us. The regular
operator must be reported on the original application
for insurance or otherwise disclosed to us and listed
on your Declarations Page before the car accident.
(9) Caused by, or as an effect of, war (declared or
undeclared), civil war, insurrection, riot, acts of
terrorism, rebellion, or revolution. This exclusion also
applies to damages caused by nuclear reaction,
radiation or radioactive contamination.
(10) Arising out of the ownership, upkeep, or use of any
vehicle other than your insured car. This exclusion
• applies only if the vehicle is owned by, furnished or
available for regular use by you or a relative.
(11) While using or occupying any car in connection with
any type of personal vehicle sharing program.
(12)Arising out of the use of a vehicle while the vehicle is
being used in the commission of a non -vehicular
felony or while attempting to elude arrest by a law
enforcement official.
(13) Punitive or exemplary damages.
Limits of Liabilitv.
Subject to these provisions, the limits shown on your
Declarations Page for this coverage are the most we will
pay in damages for any one car accident.
(1) The bodily injury limit for "each person" is the
maximum limit for all claims by all persons for
damages from bodily injury to any one person.
PAP1-1213
(2) Subject to the bodily injury limit for "each person",
the bodily injury liability limit for "each accident" is the
total limit for all claims for damages from bodily injury
to two or more persons in any one car accident.
We will pay no more than these limits despite any of the
following.
(1) The number of vehicles described or premiums shown
on your Declarations Page.
(2) The number of insured persons.
(3) The number of claims made or lawsuits filed.
(4) The number of persons making a claim.
(5) The number of policies issued by us.
(6) The number of vehicles involved in the car accident.
No stacking of uninsured motorists insurance will be
allowed by this policy.
Any amounts payable under this part will be reduced by
the following.
(1) Any payments made by or on behalf of the owner or
operator of the uninsured motor vehicle. Also any
payment made by or on behalf of any other person or
organization which may be legally liable.
(2) Any amount paid or payable under Part I or Part II of
this policy.
(3) Any payments made or payable because of bodily.
injury under any workers' compensation law or
disability benefits law or similar law.
No one will be entitled to duplicate payments under this
policy for the same elements of damages.
Other Insurance.
If there is other applicable coverage on a loss covered by
this Part, we will pay only our share of the damages. Our
share is the ratio that our limits of liability bear to the total
of all applicable limits. When an insured person is
occupying a car not listed on your Declarations Page,
this coverage is excess over any other applicable
insurance. This coverage shall apply only in the amount by
which the limits of liability for this coverage exceed the
applicable limits for such other insurance.
Arbitration.
Arbitration may occur if we and an insured person
claiming coverage under this Part do not agree to either of
the following.
(1) The legal liability of the operator or owner of an
uninsured motor vehicle.
(2) The amount of damages.
The matter may be arbitrated upon written agreement
between both parties. In this event, each party will select
an arbitrator, unless the parties agree in writing on the use
of a single arbitrator. If two arbitrators are used, they will
select a third. If the two arbitrators cannot agree on the
third within thirty (30) days, then on joint request by the
Page 8 of 13
insured and us, the third arbitrator will be appointed by a
judge or court having jurisdiction.
Disputes over coverage under this Part may not be
arbitrated.
Each party will do all of the following.
(1) Pay the expenses they incur.
(2) Bear the expenses of the single arbitrator equally.
(3) If a third arbitrator is used, bear the expenses equally.
Unless both parties agree otherwise, arbitration will take
place in the county in which the insured person lived, as
listed on the policy, immediately prior to the accident.
Local rules of procedure and evidence will apply. A
decision agreed to by two of the arbitrators, or the single
arbitrator, shall be binding as to the following.
(1) The legal liability of the operator or owner of an
uninsured vehicle.
(2) The amount of damages. The arbitrators shall have no
authority to award an amount in excess of the limits of
liability or which includes punitive or exemplary
damages.
The decision of the arbitrators is binding only for the
amount of the award that does not exceed our limits of
liability or include punitive or exemplary damages.
PART IV - CAR DAMAGE COVERAGE.
We will pay for loss to your insured car which is caused
by either of the following.
(1) Collision, but only if a premium is shown for it on your
Declarations Page.
(2) Comprehensive, but only if a premium is shown for it
on your Declarations Page.
Additional Definitions Used in This Part Only.
As used in this Part, the following definitions apply.
(1) "Collision" means actual physical contact between
your insured car and another object or upset of your
insured car.
(2) "Comprehensive" means loss to your insured car
not caused by collision. The following are examples,
but not an all inclusive list, of what is considered loss
caused by comprehensive.
(A) Missiles or falling objects
(B) Fire
(C) Theft or larceny
(D) Explosion
(E) Earthquake, windstorm or hail
(F) Water or flood
(G) Malicious mischief or vandalism
(H) Riot or civil commotion
(1) Contact with bird or animal
(J) Breakage of glass not caused by collision
If glass breakage results from a collision, you may
choose to have it treated as a loss caused by
collision.
(3) "Covered Equipment" means the following:
(A) Any permanently installed equipment, parts, or
accessories. These must have been purchased as
standard or optional equipment from the vehicle
manufacturer.
(B) Any permanently installed device designed to
record or reproduce sound. The device must have
been installed in the opening of the dash or
console. The opening must be normally used by
the manufacturer for the installation of a radio. The
maximum we will pay for loss to the device and its
accessories is $500.
(4) "Rental Vehicle" means a car you rent or hire from an
entity licensed to conduct such business under
applicable state law. The car must be in your custody
and operated by you or a relative.
(5) "Your insured car" also includes a rental vehicle
while it is being used as a temporary substitute for a
car described on your Declarations Page. The
replacement must be because of the insured car's
withdrawal from normal use due to breakdown, repair,
servicing, loss or destruction. A rental vehicle that
meets this description shall be provided the same
coverage as the vehicle it temporarily replaces.
Your Deductible.
The deductible amount shown on your Declarations Page
will be subtracted from payment of any loss covered
under this Part.
No deductible will apply to a loss to window glass when
the glass is repaired instead of replaced.
Settlement of Loss.
We may pay the loss in money or repair or replace the
damaged or stolen property. We may, at any time before
the loss is paid or the property is replaced, return, at our
expense, any stolen property. This will be returned either
to you or to the address shown on your Declarations
Page. If we repair or replace the damaged or stolen
property, we reserve the right to use parts of like kind and
quality, which may include non original equipment
manufacturer parts. We may keep all or part of the
property salvage upon payment to you of its agreed or
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appraised value. You may not abandon the damaged
property to us.
Appraisal.
You or we may demand appraisal of the loss. Each will
appoint and pay a competent and impartial qualified
appraiser. Other appraisal expenses will be shared
equally. The appraisers, or a judge or a court having
jurisdiction, will select an umpire to decide any
differences. Each appraiser will state separately the actual
cash value and the amount of loss. An award in writing by
the two appraisers, or either of the appraisers and the
umpire, will determine ttie amount payable.
We do not waive any of our rights under this policy by
agreeing to an appraisal.
Transportation Expenses.
We will pay you for reasonable substitute transportation
expenses incurred if your insured car covered by this
Part is stolen. Transportation expenses covered shall not
exceed $30 per day. The payment period begins
forty-eight (48) hours after you have told us of the theft
and have notified the police. The period ends when the
first of any of the following occurs.
(1) Seventy-two (72) hours after we make an offer to pay
the actual cash value of your insured car.
(2) When your insured car is returned to use.
(3) When $900 in substitute transportation costs has
been incurred.
Exclusions.
This coverage does not apply to loss as described by any
of the below.
(1) To your insured car while used to carry persons
or property for compensation or a fee. This
includes, but is not limited to, delivery of
newspapers, magazines, food, or any other
products. This exclusion does not apply to
shared -expense car pools.
(2) Caused by, or as an effect of, war (declared or
undeclared), civil war, insurrection, riot, acts of
terrorism, rebellion, or revolution. This exclusion
also applies to damages caused by nuclear
reaction, radiation, or radioactive contamination.
(3) To equipment used to either mechanically or
structurally change your insured car to increase
performance or change its appearance.
(4) To any closed container designed to fit in the bed
of a pickup truck, plow, winches and lift kits. This
exclusion applies whether or not the item is
permanently attached.
(5) To equipment, parts and accessories which are
not defined as covered equipment. This
exclusion does not apply if items are declared as
permanently installed in or on your insured car
and a specific premium is paid.
(6) Arising out of wear and tear, freezing, or other
temperature changes, mechanical or electrical
breakdown or failure, or manufacturers defect,
road damage to tires or other prior loss damage.
This exclusion does not apply if the loss results
from theft covered by this insurance.
(7) While your insured car is being used in, or
preparing for, any racing, speeding, stunt,
performance or demolition activity. This exclusion
applies whether or not such activity is prearranged
or organized.
(8) Arising out of the ownership, upkeep, or use of
any vehicle including your insured car, when
used for any business purpose. This exclusion
does not apply to:
(i) Use of your insured car by you or a relative
for farming or ranching.
(ii) The use of your insured car by you for auto
business operations.
(iii) Business use that has been disclosed to, and
accepted by, us.
(iv) Business use that is infrequent and not
otherwise excluded under this policy.
(9) To your insured car, if at the time of the loss,
your insured car was driven by a regular
operator who was not reported to us and listed
on your Declarations Page before the car
accident.
(10)To your insured car while it is being leased or
rented to others.
(11)To any car while being used in connection with
any type of personal vehicle sharing program.
(12) To your insured car while it's being used in used
in any illegal trade or transportation.
(13)To your insured car while it's being used in the
commission of a non -vehicular felony or while
attempting to elude arrest by a law enforcement
official.
(14) Arising out of intentional actions by or at the
direction of you or a relative, or any other person
using your insured car with your permission is
not covered. This exclusion applies when an
insured person commits an act which is, to a
large extent, certain to cause harm or damage.
This exclusion applies even if the actual result is
different than that which was intended or
expected.
(15) Due to the destruction or confiscation by
governmental or civil authorities. This exclusion
does not apply to the interests of the Loss Payees
in your insured car.
(16) Due to theft or conversion of your insured car or
its equipment which occurs prior to its delivery to
you. This exclusion also applies to theft or
conversion of such equipment which occurs after
you have delivered your insured car to a third
PAP1-1213 Page 10 of 13
party to whom you have authorized to sell, trade
or otherwise dispose of it.
(17) Due to diminution of value. This is actual or
perceived loss in market or resale value which
results from a direct and accidental loss to a car.
This exclusion also applies to diminution of any
optional equipment we insure.
(18) Due to acquiring a stolen vehicle.
(19) To your insured car due to mold, or to remedy it.
This exclusion applies despite the source of the
mold.
(20) To your insured car due to damage caused by
any explosive substance, flammable liquid or
similar hazardous materials during the
transportation of such items.
Limits of Liability.
Our limits of liability for loss shall not exceed the lesser of
the following.
(1) The actual cash value of the stolen or damaged
property at the time of loss, less the applicable
deductible.
Territory.
(2) The amount needed to repair or replace the
property or parts with those of like kind and
quality, less the applicable deductible.
To determine the actual cash value of the damaged
property at the time of the loss, an adjustment for
depreciation and physical condition will be made. The
adjustment will be in relation to physical condition and
wear and tear. If new parts are used to replace parts with
wear and tear, depreciation will be taken to the extent of
the wear and tear.
No Benefit to Bailee.
This coverage shall not in any way benefit any party caring
for or handling your insured car for a fee.
Other Insurance.
If other coverage applies on a loss covered by this Part,
we will pay only our proportionate share of the damages.
However, any insurance we may be required to provide
with respect to any non -owned vehicle used as a
temporary substitute for a vehicle listed on your
Declarations Page shall be excess over any other
collectible insurance.
PART V - GENERAL PROVISIONS.
This policy applies only to car accidents and losses
within the United States, its territories or possessions. It
also applies to car accidents in Canada, or between the
ports of the two.
Changes.
This policy, application (which is made a part of this policy
as if attached), and your Declarations Page include all the
agreements between you and us relating to this
insurance.
We will automatically give you the benefits of any
extension or broadening of this policy. That is provided
that the change does not require additional premium.
The only other way this policy can be changed is by
endorsement. Any necessary adjustment of premium will
be made at that time. We will accept certain changes to
your policy that you request. However, some changes
you request require your signature. These will be effective
only after the proper signature is obtained. Any change
will be confirmed by our issuance of a Declarations Page.
The premium for this policy is based on information we
receive from you or other sources. Changes to this
information made during the policy period may result in a
premium increase or decrease.
You must notify us within fourteen (14) days of a change
including, but not limited to:
(1) your mailing or residential address;
(2) the garaging address for any car listed on your
Declarations Page;
(3) the residents of your household and/or regular
operators of your insured car;
(4) an insured person's marital status;
(5) you or a relative obtaining a driver's license or
operator's permit; or
(6) you acquiring an additional or replacement
vehicle.
If you move to another state, we may cancel this policy in
accordance with the Cancellation or Nonrenewal of This
Policy section.
Two or More Cars Insured.
With respect to any car accident or loss to which this and
any other auto policy issued to you by us applies, the total
limit of our liability under all the policies shall not exceed
the highest applicable limit of liability under any one policy.
Lawsuit Against Us.
We may not be sued unless there has been full
compliance with all the terms of this policy. We may not
be sued under the Liability Coverage until the obligation of
an insured person is finally determined either by
judgment against that person at the actual trial, or by
written agreement of that person, the claimant and us. No
one has any right under this policy to make us a party to a
lawsuit to determine the liability of an insured person.
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We are not relieved of any duty under this policy because
of the bankruptcy or insolvency of any insured person.
Any person who 'is not an insured person under the terms
of this policy has no interest in this policy. This includes a
third party beneficiary.
This provision applies unless there first is a rendering of a
verdict against a person who is an insured person. The
verdict must be under the terms of this policy. It must be
for a claim which is covered by this policy.
Our Recovery Rights.
In the event of any payment by us under this policy, we
are entitled to all the rights of recovery against another
responsible party. This applies to the rights of any person
or organization we have paid. You and anyone we protect
must sign any papers and do whatever else is needed to
enable us to exercise our rights. You and anyone we
protect will do nothing to prejudice our rights.
If we ask, any person that we have paid must take proper
action to recover any payment we have made from any
responsible party or insurer. The action must take place in
that person's own name. We will select the attorney and
pay all related costs and fees.
When a person has been paid damages by us under this
policy and also recovers from another, the amount
recovered from the other shall be held by that person in
trust for us. That person must repay us to the extent of
our payment plus any costs or attorney fees we have to
pay.
If we make payment under any Part, we shall be entitled,
to the extent of such payment, to the proceeds of any
settlement or judgment recovered from, or on behalf of,
any responsible party. In the event of recovery from the
responsible party, to the extent of such recovery, any
rights to payment under such Part no longer exists.
If you misrepresent any fact or event that affects a risk
being eligible or results in a premium lower than that which
would have been charged we reserve the right, to recover
from you any payment we made for a loss.
Assiunment.
Interest in this policy may not be assigned without our
written consent. If the policyholder named on your
Declarations Page or their spouse who lives in the same
household dies, the policy will cover any of the following.
(1) The surviving spouse.
(2) The legal representative of the deceased. That person
must be acting within the scope of the duties as a
legal representative.
(3) Any person having proper custody of your insured
car. This applies until a legal representative is
appointed.
However, if any person is an excluded driver under this
policy, there is no coverage while that person is driving
any car.
Bankruptcy.
Electronic Signatures.
We may use electronic signatures to satisfy any
requirement for written signatures. When a law requires a
signature or letter to be notarized, verified, approved or
made under oath, the electronic signature will satisfy. This
is provided the signature of the person authorized to
perform such service is attached to or associated with the
signature of record.
Out -of -State Insurance.
If this policy provides liability insurance we will
automatically provide the compulsory motor vehicle
insurance required for nonresidents. This applies when
you are traveling in a state with such requirements.
However, we will provide only excess insurance in this
case.
Joint and Individual Interests.
Any Named Insured may cancel or change this policy. The
action of one Named Insured will be binding on all persons
provided coverage under this policy. Notices, including
premium refunds, to one Named Insured will be binding on
all persons provided coverage under this policy.
Renewal of This Policy.
Subject to our consent, you have the right to renew this
policy. When we consent to renewal, you must pay the
renewal premium before the due date. This policy will
automatically expire if we do ri($ receive the required
premium before the renewal date of the policy.
If we offer to renew the policy and you or your
representative fail to pay the required premium when due,
you have not accepted our offer. This is also the case if
we bill for a balance due from a policy change and you fail
to pay when due. If that happens, this policy may
automatically terminate on the date noted on the renewal
notice.
Cancellation or Nonrenewal of This Policy.
The Named Insured, listed on your Declarations Page may
cancel this policy by advising us in writing of the future
date the cancellation is to take effect.
We may cancel your policy for any reason permitted by
the state in which your policy is written. A cancel notice
will be mailed to the person listed as Named Insured at the
address shown on your Declarations Page. Mailing of the
notice will be in alignment with required timeframes.
If we decide not to renew this policy, we will mail notice of
nonrenewal according to the state law where your policy
is written. This notice will be mailed to the person listed as
Named Insured at the address shown on your
Declarations Page. Proof • of mailing a cancel or
nonrenewal notice shall be sufficient proof of notice, if
required.
PAP1-1213 Page 12 of 13
Upon cancellation you may be due a premium refund. If
so, we will send it to you. A refund is not a condition of
cancellation. If we cancel, any refund will be computed on
a pro -rats basis. If you cancel, the refund will be
computed via customary short -rate methods and
procedures. The effective date of cancel stated in a notice
is the end of the policy period.
Misrepresentations.
If you misrepresent any fact or condition that affects
whether a risk is eligible or contributes to a loss, we
reserve the right to rescind the policy and/or deny
coverage. This also applies if the misrepresentation
avoids premium owed to us or results in a premium lower
than that which would have been charged if true and
complete information had been provided.
Should we be required to cover such a loss, we reserve
the right to recover all resulting payments from you.
In Witness Whereof, we have caused this policy to be signed by its President and Secretary. If required by state law, this
policy shall not be valid unless countersigned by our authorized representative.
Secretary
NOTICE OF OUR INFORMATION PRACTICES.
We are required by Public Law 91-508, Fair Credit
Reporting Act to inform you as follows. As part of our
procedure for processing and reviewing applications, a
credit report, motor vehicle report or other underwriting
reports may be obtained. An investigative report may also
be obtained through personal interviews with third parties.
Some examples of third parties include family members,
business contacts, financial sources, friends, neighbors,
or others acquainted with you. This inquiry includes
information as to your character, general reputation,
personal characteristics, and mode of living or driving
PAP1-1213
President
history, as applicable. This process also applies to our
review of new policies, renewal policies and policies
currently in effect. You have the right to make a request
for a complete and accurate disclosure of additional
information about the nature and scope of the
investigation. The request must be to this company and
be within a reasonable time period. You have the right to
dispute such information which you believe to be in error.
Page 13 of 13
19 00018 0001168 21268-1 N A 0
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PERSONAL AUTO POLICY AMENDATORY ENDORSEMENT - CALIFORNIA
All terms and conditions of the Personal Auto Policy and
any other endorsements also apply to this endorsement,
except as changed by this endorsement.
Exclusions.
Exclusion (7) is deleted.
DEFINITIONS USED THROUGHOUT THIS POLICY. PART V - GENERAL PROVISIONS.
Definition (3) is replaced in its entirety by the following:
(3) "Relative" means a person living in your household.
This person must be related to you by blood,
marriage, registered domestic partnership under
California law, or adoption. Relative includes a ward,
foster child or a minor under your guardianship who
lives in your household. Your unmarried dependent
children living temporarily away from home qualify as a
relative only if they intend to continue to live in your
household.
PART I - LIABILITY COVERAGE.
Additional Definitions Used in This Part Only.
As used in this Part, these definitions apply.
(1) "Insured person" or "insured persons" means all of
the following.
(A) You.
(B) A relative.
(C) Any other person using your insured car provided
the use is with the permission of the Named
Insured(s) shown on your Declarations Page,
express or implied, and within the scope of that
permission.
No one is considered an insured person if they use a car
without the permission or outside the scope of the
permission of the owner.
Additional Payments.
Additional Payments (4) is replaced by the following.
(4) Up to $100 a day of lost wages when we ask an
insured person to attend trials or hearings.
Exclusions.
Exclusion (10) is replaced by the following.
(10) Bodily injury to you or an insured person.
The following exclusion is added.
(19) Bodily injury to you or any relative whenever the
ultimate benefits of that indemnification accrue
directly to you or any relative.
Exclusion (11) is deleted.
PART IV - CAR DAMAGE COVERAGE.
Your Deductible.
The last paragraph under this provision is deleted.
Changes.
This provision is replaced by the following.
Changes.
This policy, application (which is made a part of this policy
as if attached), and your Declarations Page include all the
agreements between you and us relating to this
insurance.
We will automatically give you the benefits of any
extension or broadening of this policy. That is provided
that the change does not require additional premium.
The only other way this policy can be changed is by
endorsement. Any necessary adjustment of premium will
be made at that time. We will accept certain changes to
your policy that you request. However, some changes
you request require your signature. These will be effective
only after the proper signature is obtained. Any change
will be confirmed by our issuance of a Declarations Page.
The premium for this policy is based on information we
receive from you or other sources. Changes to this
information made during the policy period may result in a
premium increase or decrease.
You must notify us within fourteen (14) days of a change
including, but not limited to:
(1) your mailing or residential address;
(2) the garaging address for any car listed on your
Declarations Page;
(3) the residents of your household and/or regular
operators of your insured car;
(4) an insured person's marital status;
(5) you or a relative obtaining a driver's license or
operator's permit;
(6) you acquiring an additional or replacement
vehicle; or
(7) your email address, if you requested electronic
notice or delivery of documents.
If you move to another state, we may cancel this policy in
accordance with the Cancellation or Nonrenewal of This
Policy section.
If a change results in a lower premium, we reserve the
right to apply the unearned premium generated by the
change to the balance owed on your policy as a whole,
rather than tender a refund of the unearned premium.
PPA-CA-1120
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Page 1 of 2
Cancellation or Non -Renewal of This Policv.
The Named Insured, as listed on your Declarations Page
may cancel this policy by advising us in writing of the
future date the cancellation is to take effect.
We may cancel for nonpayment of premium at any time by
providing at least ten (10) days notice of cancellation.
We may cancel for one or more of the following reasons by
providing at least twenty (20) days' notice.
(A) For suspension or revocation of your driver's
license or that of any other operator who either,
lives in your household or customarily operates
your insured car. The suspension or revocation
must have taken place during the policy period or,
if a renewal policy, within 180 days prior to the
most recent renewal effective date.
(vii) Any other factor found by the Commissioner
of Insurance to have a substantial relationship
to the risk of loss.
Provided, however, that such cancellation will not
take effect if the insured person furnishes
corrected information to us within (twenty) 20
days of receipt of the Notice of Cancellation and
further agrees to pay any difference in premium
for the policy period(s) in which the information
remained undisclosed.
If different requirements for cancellation and non -renewal
or termination of policies are applicable because of the
laws of your state, we will comply with those
requirements.
We are required by Section 663 of the California
Insurance Code to notify you of the following:
(B) For fraud by you in pursuing a claim under the We may nonrenew your policy by providing at least thirty
policy, provided we do not rescind the policy; or (30) days notice.
(C) For material misrepresentation of any of the Mailing or electronic delivery of any notice of cancellation
following information concerning you or any or nonrenewal will be to the person listed as the Named
resident of your household who customarily Insured on your Declarations page at the address shown
operates your insured car: on your Declarations Page.
(i) Safety record;
(ii) Annual miles driven in prior years;
(iii) Number of years of driving experience;
(iv) Record of prior automobile insurance claims, if
any;
(v) Permissive use of your insured car by
persons, other than you and principal or
occasional drivers, to the extent that indicates
regular use of your insured car by such
persons;
(vi) Conditions, alterations or modifications of
your insured car that renders it unsafe in
violation of California or federal safety
requirements; or
Proof of mailing or electronic delivery of a notice of
cancellation or nonrenewal shall be sufficient proof of
notice of cancellation or nonrenewal.
If this policy is cancelled, you may be entitled to a
premium refund. If so, we will send you the refund.
However, making or offering to make the refund is not a
condition of cancellation. The effective date of the
cancellation stated in a notice is the end of the policy
period.
The following provision is added.
If other insurance is obtained on your insured car, any
similar insurance afforded under this policy for that car will
cease on the effective date of the other insurance.
PPA-CA-1120 Page 2 of 2
WARNING
Unless you have automobile or aircraft insurance written by a Mexican insurance
company, you may spend many hours or days in jail, if you have an accident in
Mexico. Insurance coverage should be secured from a company licensed under the
laws of Mexico to write such insurance in order to avoid complications and some
other penalties possible under the laws of Mexico, including the possible
impoundment of your automobile or aircraft.
MEXICO LIMITED COVERAGE ENDORSEMENT
The coverages for your insured car provided by this your Declarations Page.
policy are extended to car accidents that occur in Mexico
within twenty-five (25) miles of the United States border. Special Conditions.
This extension will not apply if all insured persons (1) Other Insurance. The insurance we provide by this
collectively have made more than five (5) trips into Mexico endorsement will be excess over any other collectible
during the thirty (30) days prior to the date of loss. insurance.
This extension will not apply if all insured persons (2)
collectively have spent more than ten (10) days in Mexico
during the thirty (30) days prior to the date of loss.
Additional Exclusions.
We do not provide any coverage:
Losses payable under Part IV - Car Damage
Coverage. We will pay losses under Car Damage
Coverage in the United States not Mexico. If your
insured car must be repaired in Mexico in order to be
driven, we will not pay more than the actual cash
value of such loss at the nearest United States point
where the repairs can be made.
(1) If your insured car is not principally garaged and (3) Duty to Defend. Our duty to defend under Part I does
used in the United States; not apply unless:
(2) While occupying a car other than your insured car; (A) The original lawsuit for damages is brought in the
or United States; and
(3) To any person while your insured car is being used (g) The lawsuit does not involve a Mexican citizen or
by a citizen or resident of Mexico. This exclusion does resident. This does not apply to the Named
not apply to Loss Payable under Part IV if the accident Insured or any driver as listed on your
arises out of the operation of your insured car by a Declarations Page.
Mexican citizen or resident. This exclusion does not
apply to the Named Insured or any driver as listed on
MCEI-CA-1117
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Viking Insurance Company of Wisconsin
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My.Dairylandl nsurance.com
CALIFORNIA UNINSURED MOTORISTS BODILY INJURY COVERAGE
REJECTION
REJECTION OF UNINSURED MOTORISTS BODILY INJURY COVERAGE
"The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability
insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those
provisions also permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a
motor vehicle is operated by a natural person or persons designated by name. Uninsured motorists coverage insures
the insured, his or her heirs, or legal representatives for all sums within the limits established by law, that the person or
persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death,
to the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a
resident of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in
subdivision (p) of Section 11580.2 of the Insurance Code."
WE STRONGLY RECOMMEND YOU PURCHASE THIS COVERAGE.
I have read and understand the above information, and I have decided not to purchase this coverage.
Named Insured's Signature
Date
CAUM-0517
25 00018 0001168 21268-1 N A 0
(Pol#11407299563)
0027020044362439658495020614151
Pagel of 1
Viking Insurance Company of Wisconsin
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CALIFORNIA UNINSURED MOTORISTS PROPERTY DAMAGE COVERAGE
REJECTION
REJECTION OF UNINSURED MOTORISTS PROPERTY DAMAGE COVERAGE
The California Insurance Code requires an insurer to offer coverage for damage to the insured motor vehicle, to the
extent that you are legally entitled to recover, from the owner or operator of the uninsured motor vehicle, caused by an
uninsured motor vehicle, that either:
(1) Pays the collision deductible on the insured motor vehicle (when you have purchased collision coverage), or
(2) Pays for the damage to the insured motor vehicle (when you have not purchased collision coverage).
Payment does not include damage to personal property or loss of use of a motor vehicle and shall not exceed the
smaller of any of the following:
(A) The amount of the collision deductible, or
(B) The actual cash value of the loss or damage to the insured motor vehicle, or
(C) $3,500.
You may reject such coverage completely or reject such coverage when an insured motor vehicle is operated by a
natural person or persons designated by name.
I have read and understand the above information, and I have decided not to purchase this coverage.
Named Insured's Signature
CAUMPD-0517 (Pol #11407299563)
Date
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27 0001E 0001168 21268-1 N A 0 0027020044362439658495020614151
NOTICE OF INFORMATION PRACTICES
This notice replaces any previously issued Notice of Information Practices
Many people are concerned about the use of their personal information. We want to share with you our policy regarding
the collection and disclosure of your information.
Information Collection
We may collect information about you from the following sources:
Information we receive from you on applications or other forms. On some occasions our Producer, employees or a
policy verification service will contact you by mail, telephone or in person for additional information we need.
Information about your transactions with us, our affiliates or others.
Information we receive from state motor vehicle records, court records, credit reports and insurance, or consumer
reporting agencies as permitted by law.
Information from members of your family, insurance Producers or others who know you.
If a report is ordered which involves obtaining information from other than court records or a reporting agency, we will
notify you. You may request to be interviewed by the company making the report and obtain a copy of this report.
Information Disclosure
Occasionally, we may have to give information we collect about you to others. We may disclose information about you:
To enable us to process, service and administer insurance transactions, including underwriting your policy and
adjusting a claim;
To detect or prevent criminal activity, fraud, material misrepresentation or material nondisclosure;
To an insurance regulatory authority;
To a law enforcement or other government authority;
To conduct actuarial or research studies; or
To affiliates and nonaffiliated third parties as permitted by law.
We do not disclose information about our former customers, except as permitted by law. Information obtained by an
insurance support organization may be retained by the insurance support organization and disclosed to other persons.
We restrict access to nonpublic personal information about you to those employees who need to know that information
to provide products or services to you. We maintain physical, electronic and procedural safeguards to guard your
nonpublic personal information.
A consumer or insurance reporting company working for us or a claim adjustment company handling our losses may
need certain information to do its job. Sometimes we are required to disclose information to insurance regulators, to law
enforcement agencies or in response to court subpoena. Other disclosures to third parties will be made only with your
permission.
Access to our Records and Correction of File Information
You have the right to review recorded information in our files. An exception to this is information concerning claims or
lawsuits. Please give us identification (your name, address, policy number and name of your Producer) and the
information you would like to receive. We will respond within 30 days. You may also see a copy of your recorded
information in person at our main office within 30 days of a request. We will also tell you to whom we have given any of
this information within the past two years, plus, the name and address of any consumer reporting agency which
prepared any report in our files.
Tell us if any of this information is incorrect. We will within 30 days of receipt from you, correct, amend, or delete any
erroneous information in our files and tell others to whom we may have given such information within the past 2 years (7
years for information sent to support organizations). We will let you know if we disagree with your request for correction.
You then have the right to send us a statement of what you believe is the correct information and why you continue to
disagree with our records. Your statement will then be included in our file and in any disclosures we have made or will
make.
You are our customer
You are a customer of one of the companies shown below. All operate under the same management. Common
underwriting records and personal information are maintained. We value you as a customer so your privacy is our
concern. You can be certain that we gather information only in the interest of providing you with a quality product and
service at the lowest possible price. If you have any questions contact us at: PO Box 8034, Stevens Point, WI
54481-8034. Telephone 1-800-334-0090.
PEAK PROPERTY AND CASUALTY INSURANCE CORPORATION, VIKING INSURANCE COMPANY OF WISCONSIN, DAIRYLAND
INSURANCE COMPANY, DAIRYLAND COUNTY MUTUAL INSURANCE COMPANY OF TEXAS, PATRIOT GENERAL INSURANCE
COMPANY, MIDDLESEX INSURANCE COMPANY, SENTRY INSURANCE COMPANY
PHNS-0613 Page 1 of 1
29 00018 0001168 21268-1 N A 0 0027020044362439658495020614151
IMPORTANT POLICYHOLDER NOTICES - CALIFORNIA
CONSUMER AFFAIRS NOTIFICATION
If there are any questions concerning your policy, please This information is provided in accordance with California
contact your producer as listed on your declaration page law. Consumer complaints may be reported to the below
or billing notice. You may also contact us using the below agency. The Consumer Services Bureau should be
address or telephone number. contacted only after discussions with the company or your
Please have your policy number readily available to assist producer have failed to produce a satisfactory solution toyour problem.
us in helping you.
Viking Insurance Company of Wisconsin California Department of Insurance
PO Box 8034 Consumer Services Bureau
Stevens Point, WI 54481-8034 300 South Spring Street
Los Angeles, CA 90013
Toll Free Number 1-800-334-0090 Telephone: (800)-927-4357
Department of Insurance Internet Website:
www.insurance.ca.gov
SURCHARGE DISCLOSURE
In accordance with California Insurance Laws, Chapter 5,
Section 489, the following information is provided to you:
Premiums for your policy are affected by any chargeable
accident(s) and/or ticket(s) received by the drivers of your
vehicle. Please note that almost all tickets are assigned
surcharge points, not just major violations. Higher
premiums are charged based on the following:
1) The number of years driving experience, gender and
marital status of each driver; and/or
2) The number of surcharge points accumulated during
the preceding 36 months for each driver; and/or
3) Which driver has the highest number of surcharge
points_
PHNI-CA-0816 Page 1 of 1
CALIFORNIA DISCOUNTS
Viking Insurance Company of Wisconsin offers the following discounts for its California auto products:
• Multi -Car
• Mature Driver Improvement Course (Age 55 and Older)
• Good Driver
Contact your independent insurance producer for additional information or questions about your policy.
CALIFORNIA FEES
As a policyholder of Viking Insurance Company of Wisconsin, you are subject to premiums and fees the company has
filed and approved with the California Department of Insurance. These fees include:
Amount
Description
Policy
$0
.�wWwaWxxwc
One-time fee applies to all new policies.
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Renewal
1etoDeveoceP>sooeoeeo«
$10
Fee a lies each time a policy renews.
%.et<9H mea�zeox!eeou3xeow.3cxe!ece�sro�(Ko oxaaou(aaoaaLaaaeuwewaaee0.eow(uLc
Installment
$10
Fee applies to each installment bill.
xawwawwawax�eeXatee!aar.3wmbaw»xtaWtde((td%Keoaaa%ozW»casaa�%aaaaLaLa4
EFT Renewal
M<aJRaKOfL<aitKOS3X4.!C4(LK<K!<!{<IW.H(KMdIMHN!C<K<OtM/ASattfoCtt!a(3%mcaCKKa(aaK(tiLa0Mfa4'SKM!aWSi!MLP95N.LL3KM!d9d<d.N:(LcaaaN<a<C.«V.(((Ka(Ky{!a::{:ti:Li4:LU.C{.W.ti<!tit!.L[M:!N!!!!M:!at!NO%!Hl.:<M!CetH.:u;�[4:!(:FO::K<(Jc(W:K:K:o:ta(KGWS:aL(Lan�A!LW.:�riv.<vW%(itt'rii:aitiv4ii%!<aK-L!!:(((KaW.(%Wc(A:LxM::3N(Y.KKtt:ttOCXI:KN.!M!MK<K!tK(S<NtpSSMS
$8
Fee applies each time an EFT policy renews.
EFT Installment
$8
aatadweeaeeee LtoaedtLaeaewaa(aa(aLaLa!eeaace!arw�wee3eaexy3a3rcx(t(aLa<auwacuaLaKae<aaaaaaaaaKaaL(Lw!w!aL(W(w:LaWa!Laaaeaue(aeexWaow�auLa!(onaaa(a(aeLawxaro!euoacaLaummeaueattaaue
Fee applies to each EFT installment bill.
Reissue
M!MStt�Yt!!N!C%((pC(W:�a(aKW.P'L.HaGO!r%dL!Ltd!!tY.t3M!!MN!M!M%fJOY.EA[CNMM00.'C?'/.WfOn
$10
.iC.:iT'.nKf(.%OOKiMa<.WYi:Y{tiM!!LS3:A43X!!K^"�KC:�JfOt!Kec!xKN.!wxM�:OUK;:(/nro:4':.:aK.e(o:i(K(:W%(%0.r%r�ri!iN<:4M.%Nb..:!N.!%M.:!KM::l.3:!Xh:3:<Y.CXCX(N:K«Y.:. ....
Fee applies when policy lapses and needs to be reissued.
%�%L:a((AW:SL:KK:a((w<O:(OOtaX:LKAdtf%Li0(-0!d:!NM:SK!!!!!thMtd!:N.!N.^:XM::34A'LKL3}S(dSCCS<ftilOKWdiW
CA Fraud Assessment
$0.14 per vehicle, per month
Fee applies to new business and renewal.
NOTE. All fees, except the Fraud Fee, are subject to a 20% discount if the Good Driver Discount is applied to the policy.
Any fees charged to you in addition to those listed above are done solely at the discretion of your independent
insurance producer. Fees vary by office.
Policies and coverages are underwritten by Viking Insurance Company of Wisconsin, a member of the Sentry Insurance Group, Stevens Point, WI.
PHN2-CA-0617 Page 1 of 1
31 00018 0001168 21268-1 N A 0
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Viking Insurance Company of Wisconsin
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My.Dairylandl nsurance.com
CALIFORNIA NOTICE OF DESIGNATED ADDITIONAL
PERSON TO RECEIVE NOTICE OF CANCELLATION
OR NONRENEWAL
Additional Person To Receive Notice Of Cancellation Or Nonrenewal
Policy Number: 11407299563'
Name/Address:
In accordance with CAL INS. CODE § 396, we are notifying you of your right to designate one additional person to
receive notice of lapse, termination, expiration, nonrenewal, or cancellation of your policy for nonpayment of premium.
You may establish or change the designated person by completing this form and mailing or delivering to us. No benefit
under your policy is provided to the designated person by this Notice, other than the right to receive the aforementioned
notice.
CA1106-1115 (POI #11407299563) Pagel of 1
Viking Insurance Company of Wisconsin
�airWland,
My.Dairylandlnsurance.com
CALIFORNIA RACE, NATIONAL ORIGIN & GENDER REQUEST
COMMUNITY SERVICE STATEMENT
In order to aid the Insurance commissioner of the State of California to monitor the insurer's compliance with the law, all
applicants (Named Insureds) on the application are requested to voluntarily provide the following information. No such
information shall be used for purposes of underwriting or rating any applicant.
Named Insured: RODRIGUEZMEJIA, MARVIN A
Gender: ® Male ❑ Female ❑ Non -Binary
Address: 7351 Rosanna St
City: Gilroy
State: CA Zip: 95020
Check the Race or National Origin as it applies to the applicant.
❑ African American
❑ Latino
❑ American Indian or Alaskan Native
❑ White
❑ Asian / Pacific Islander
❑ Other
® Check here if the applicant does not wish to provide the Department of Insurance with this information.
CA3067-1219
Pagel of 1
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PREMIUM MUST BE PAID FOR COVERAGE TO BE 1N FORCE
CALIFORNIA AUTOMOBILE
INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy 11407299563
Effective Date 09/24/2021
Expiration Date 03/24/2022
Year 2014 Make Volkswagen
Model JETTA S
VIN 3VW2K7AJ2EM300823
Named Insured(s)
RODRIGUEZMEJIA, MARVIN A
7351 Rosanna St
Gilroy CA 95020
Agency Agency Phone 408-842-1990
COAST AUTO INS #6
401 E 10TH ST STE 2
GILROY CA 95020
If you are in an accident, call us as soon as possible at
1-800-334-0090. We are available 24 hours a day to take your
call. See reverse side for additional information.
CALIFORNIA AUTOMOBILE
INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy 11407299563
Effective Date 09/24/2021
Expiration Date 03/24/2022
Year 2014 Make Volkswagen
Model JETTA S
VIN 3VW2K7AJ2EM300823
Named Insured(s)
RODRIGUEZMEJIA, MARVIN A
7351 Rosanna St
Gilroy CA 95020
Agency Agency Phone 408-842-1990
COAST AUTO INS #6
401 E 10TH ST STE 2
GILROY CA 95020
If you are in an accident, call us as soon as possible at
1-800-334-0090. We are available 24 hours a day to take your
call. See reverse side for additional information.
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My. Dairyland I nsurance.com
IN CASE OF AN ACCIDENT
Obtain the following information...
1. Name and address of each driver, passenger and
witness.
2. Name of insurance company and policy number for
each vehicle involved.
COVERAGE COMPLIES WITH MINIMUM AMOUNT OF
v LIABILITY INSURANCE REQUIRED. THIS CARD SERVES
u AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY
FINANCIAL RESPONSIBILITY.
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YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR
POSSESSION AND PRODUCE IT UPON DEMAND.
THIS CARD IS NOT PART OF YOUR POLICY AND IS
EFFECTIVE ONLY WHILE YOUR INSURANCE REMAINS IN
FORCE. THIS CARD NEITHER AFFIRMATIVELY NOR
NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
o COVERAGE AFFORDED BY YOUR POLICY.
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E IN CASE OF AN ACCIDENT
Obtain the following information...
1. Name and address of each driver, passenger and
witness.
2. Name of insurance company and policy number for
each vehicle involved.
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_ COVERAGE COMPLIES WITH MINIMUM AMOUNT OF
LIABILITY INSURANCE REQUIRED. THIS CARD SERVES
U- ; AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY
FINANCIAL RESPONSIBILITY.
YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR
POSSESSION AND PRODUCE IT UPON DEMAND.
THIS CARD IS NOT PART OF YOUR POLICY AND IS
EFFECTIVE ONLY WHILE YOUR INSURANCE REMAINS IN
FORCE. THIS CARD NEITHER AFFIRMATIVELY NOR
u, NEGATIVELY AMENDS, EXTENDS OR ALTERS THE
o COVERAGE AFFORDED BY YOUR POLICY.
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