Endorsement Summary and Receipt

Note: This endorsement application must be approved and issued by Freedom General's underwriting department. Any false
statements may result in the cancellation or rescission of this policy.

Policy Information
Policy No.: HAJ115091 Customer No.: 394434 Customer Name: CONNIE KOUF

Summary of Endorsement
1. Endorsement Submitted: by CONNIE KOUF (Customer) on Oct 4 2017 7:44PM from IP Address 172.58.21.58
2. Proposed Endorsement Effective Date: 10/05/2017.
3. Added Vehicle: 2004 CHRYSLER SEBRING TOURING [VIN: 1C3EL55R64N311768].
a. Coverages: BI: $15,000/$30,000; PD: $10,000; MEDPAY: No Coverage; UMBI: No Coverage; UIMBI: No
Coverage; COMP: No Coverage; COLL: No Coverage; RENT: No Coverage; Business/Artisan Use: No.
b. Loss Payee: NONE.
Premium Change
Additional Premium Due: $91.46
Approximate New Monthly Payment: $143.86

Receipt
Paid $91.46 by Credit Card **** **** **** 4086 on 10/4/2017 7:45:53 PM PST towards required deposit shown above.
Confirmation #: 171004194552373115598368

I hereby authorize Freedom National Insurance Services, Inc. ("Freedom National") to charge the credit or debit card that I have
entered for the amount stated above. I am aware that in the event Freedom National is unable to secure funds from my account
for this transaction for any reason, Freedom National may take further collection action and returned payment fees may apply, to
the extent permitted by law. I understand that if the payment is returned by my card issuer, I am still responsible for making a
payment on my Freedom National policy to avoid cancellation.

Required Items *** Attention *** *** Attention *** *** Attention *** *** Attention ***
None

Temporary ID Card
Next Page

"Thank you for using endorse"

Page 1 of 1
STATE: AZ TEMPORARY IDENTIFICATION CARD LOYAL CUSTOMER SINCE 2015
NAMED DRIVERS
NAIC CODE COMPANY CONNIE KOUF
10807 ACCC Insurance Company
P.O. Box 7820 Newport Beach, CA 92658

POLICY NUMBER EFFECTIVE DATE * EXPIRATION DATE

HAJ115091 9/19/2017 3/19/2018 THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER * Effective date on the permanent ID card issued by Freedom may exhibit a different date.
2005 NISSAN/SENTRA 1.8 3N1CB51D35L502374 IN CASE OF ACCIDENT: Report all accidents to ACCC Insurance
BASE/SENTRA 1.8 S
Company as soon as possible: (888) 823-0888
BROKER/COMPANY ISSUING CARD INSURED
4144 (PHOENIX) KOUF, CONNIE Every person is required to possess evidence of financial responsibility
1601 W SUNNYSIDE DR UNIT within the motor vehicle. This card is satisfactory evidence of
PHOENIX, AZ 85029-3775 mandatory financial responsibility for purposes of verifying financial
responsibility on your motor vehicle upon request from the ADOT.
Meets the Requirements of Section 28-4009 and 28-4033.
SEE IMPORTANT NOTICE ON REVERSE SIDE ACORD 50 (2/95) (7/05) © ACORD CORPORATION 1993

STATE: AZ TEMPORARY IDENTIFICATION CARD LOYAL CUSTOMER SINCE 2015

NAMED DRIVERS
NAIC CODE COMPANY CONNIE KOUF
10807 ACCC Insurance Company
P.O. Box 7820 Newport Beach, CA 92658

POLICY NUMBER EFFECTIVE DATE * EXPIRATION DATE

HAJ115091 9/19/2017 3/19/2018 THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER * Effective date on the permanent ID card issued by Freedom may exhibit a different date.
2004 CHRYSLER/SEBRIN 1C3EL55R64N311768 IN CASE OF ACCIDENT: Report all accidents to ACCC Insurance
G TOURING
Company as soon as possible: (888) 823-0888
BROKER/COMPANY ISSUING CARD INSURED
4144 (PHOENIX) KOUF, CONNIE Every person is required to possess evidence of financial responsibility
1601 W SUNNYSIDE DR UNIT within the motor vehicle. This card is satisfactory evidence of
PHOENIX, AZ 85029-3775 mandatory financial responsibility for purposes of verifying financial
responsibility on your motor vehicle upon request from the ADOT.
Meets the Requirements of Section 28-4009 and 28-4033.
SEE IMPORTANT NOTICE ON REVERSE SIDE ACORD 50 (2/95) (7/05) © ACORD CORPORATION 1993

STATE: TEMPORARY IDENTIFICATION CARD LOYAL CUSTOMER SINCE

NAMED DRIVERS

VOID VOID
NAIC CODE COMPANY

P.O. Box 7820 Newport Beach, CA 92658

POLICY NUMBER EFFECTIVE DATE * EXPIRATION DATE

THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER * Effective date on the permanent ID card issued by Freedom may exhibit a different date.

BROKER/COMPANY ISSUING CARD INSURED

Meets the Requirements of Section 28-4009 and 28-4033.
SEE IMPORTANT NOTICE ON REVERSE SIDE
Every person is required to possess evidence of financial responsibility
within the motor vehicle. This card is satisfactory evidence of
mandatory financial responsibility for purposes of verifying financial
responsibility on your motor vehicle upon request from the ADOT.
ACORD 50 (2/95) (7/05) © ACORD CORPORATION 1993

STATE: TEMPORARY IDENTIFICATION CARD LOYAL CUSTOMER SINCE

NAMED DRIVERS

VOID VOID
NAIC CODE COMPANY

P.O. Box 7820 Newport Beach, CA 92658

POLICY NUMBER EFFECTIVE DATE * EXPIRATION DATE

THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER * Effective date on the permanent ID card issued by Freedom may exhibit a different date.

BROKER/COMPANY ISSUING CARD INSURED

Meets the Requirements of Section 28-4009 and 28-4033.
SEE IMPORTANT NOTICE ON REVERSE SIDE
Every person is required to possess evidence of financial responsibility
within the motor vehicle. This card is satisfactory evidence of
mandatory financial responsibility for purposes of verifying financial
responsibility on your motor vehicle upon request from the ADOT.
ACORD 50 (2/95) (7/05) © ACORD CORPORATION 1993