Form_SCTNID_CTGRY.

PA08196489_DECPAGE

933208004 E GC60036 INS DECPAGE E POLWHITEFONT M4OAIMBQ5VS7UB27373FLRNM7A0001 RPUID TRACWHITEFONT

FLOREY INS AGENCY

1186 WINOLA RD
CLARKS SUMMIT, PA 18411

Policy Number: 933208004

Underwritten by:
Progressive Specialty Insurance Co
June 10, 2022
LUIS M LOPEZ RUIZ
Policy Period: May 7, 2022 - Nov 7, 2022
201 N MAIN ST
TAYLOR, PA 18517 Page 1 of 3

1-570-587-2615
FLOREY INS AGENCY
Contact your agent for personalized service.

agent.progressive.com
Auto Insurance Online Service

Coverage Summary
Make payments, check billing activity, update
policy information or check status of a claim.

This is your Declarations Page 1-800-274-4499

To report a claim.
Your coverage has changed
Your coverage began on May 7, 2022 at 12:01 a.m. This policy expires on November 7, 2022 at 12:01 a.m.
This coverage summary replaces your prior one. Your insurance policy and any policy endorsements contain a full explanation of your
coverage. The policy limits shown for a vehicle may not be combined with the limits for the same coverage on another vehicle, unless
the policy contract or endorsements indicate otherwise. The policy contract is form 9611A PA (02/16). The contract is modified by form
A230 (11/16).

COLLISION COVERAGE FOR RENTAL VEHICLES

IF THIS POLICY PROVIDES COLLISION COVERAGE, IT WILL APPLY TO VEHICLES YOU RENT, BUT NOT TO
VEHICLES RENTED FOR 6 MONTHS OR MORE.
FRAUD NOTICE
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.

Policy changes effective June 7, 2022

………………………………………………………………………………………………………………………………………………………..
Changes requested on: Jun 6, 2022
………………………………………………………………………………………………………………………………………………………..
Requested by: Progressive
………………………………………………………………………………………………………………………………………………………..
Premium change: -$3.33
………………………………………………………………………………………………………………………………………………………..
Changes: Coverage has been changed on the policy.

Underwriting Company
Progressive Specialty Insurance Co
P.O. Box 6807
Cleveland , OH 44101
1-800-876-5581

Drivers and ………………………………………………………………………………………………………………………………………………………..

resident relatives Additional information
LUIS M LOPEZ RUIZ First Named insured
………………………………………………………………………………………………………………………………………………………..
ADIZ VELIZ

Form 6489 PA (08/19)

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Continued
933208004 E GC60036 INS DECPAGE E POLWHITEFONT M4OAIMBQ5VS7UB27373FLRNM7A0001 RPUID TRACWHITEFONT

Policy Number: 933208004

LUIS M LOPEZ RUIZ
Page 2 of 3

Outline of coverage
2010 VOLKSWAGEN JETTA 4 DOOR SEDAN
VIN: 3VWRZ7AJ1AM068560
Garaging ZIP Code: 18517
Primary use of the vehicle: Commute
Length of vehicle ownership when policy started or vehicle added: 5 years or more
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $162
Bodily Injury Liability $15,000 each person/$30,000 each accident
Property Damage Liability $5,000 each accident
………………………………………………………………………………………………………………………………………………………..
First Party Benefits 30
Medical Expenses $5,000 each person
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist - Nonstacked $15,000 each person/$30,000 each accident 5
………………………………………………………………………………………………………………………………………………………..
Underinsured Motorist - Stacked $15,000 each person/$30,000 each accident 10
………………………………………………………………………………………………………………………………………………………..
Comprehensive Actual Cash Value $500 62
………………………………………………………………………………………………………………………………………………………..
Roadside Assistance 7
………………………………………………………………………………………………………………………………………………………..
Total premium for 2010 VOLKSWAGEN $276
2018 MITSUBISHI OUTLANDER 4 DOOR WAGON
VIN: JA4AZ3A33JZ062519
Garaging ZIP Code: 18517
Primary use of the vehicle: Commute
Length of vehicle ownership when policy started or vehicle added: At least 1 year but less than 3 years
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $151
Bodily Injury Liability $15,000 each person/$30,000 each accident
Property Damage Liability $5,000 each accident
………………………………………………………………………………………………………………………………………………………..
First Party Benefits 32
Medical Expenses $5,000 each person
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist - Nonstacked $15,000 each person/$30,000 each accident 5
………………………………………………………………………………………………………………………………………………………..
Underinsured Motorist - Stacked $15,000 each person/$30,000 each accident 17
………………………………………………………………………………………………………………………………………………………..
Comprehensive Actual Cash Value $500 98
………………………………………………………………………………………………………………………………………………………..
Collision Actual Cash Value $500 482
………………………………………………………………………………………………………………………………………………………..
Rental Reimbursement up to $40 each day/maximum 30 days 64
………………………………………………………………………………………………………………………………………………………..
Roadside Assistance 5
………………………………………………………………………………………………………………………………………………………..
Total premium for 2018 MITSUBISHI $854
………………………………………………………………………………………………………………………………………………………..
Total 6 month policy premium $1,130.00

Premium discounts
Policy
………………………………………………………………………………………………………………………………………………………..
933208004 Multi-Car, Continuous Insurance: Gold and Paperless
Vehicle
………………………………………………………………………………………………………………………………………………………..
2010 VOLKSWAGEN Driver and Passenger-side Airbag and Passive Anti-theft Device
JETTA
2018 MITSUBISHI Driver and Passenger-side Airbag, Passive Anti-theft Device and Smart
OUTLANDER Technology Discount

Smart Technology Discount ℠ is a service mark of Progressive Casualty Ins. Co.

Tort Option
This policy provides limited tort insurance.

Form 6489 PA (08/19)

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933208004 E GC60036 INS DECPAGE E POLWHITEFONT M4OAIMBQ5VS7UB27373FLRNM7A0001 RPUID TRACWHITEFONT

Policy Number: 933208004

LUIS M LOPEZ RUIZ
Page 3 of 3

Information Regarding Your Premium

A surcharge of $117.00 due to violations or accidents is included in the total policy premium.

Company officers

President Secretary

Form 6489 PA (08/19)