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DECLARATIONS
New Business Infinity Insurance Company
DECLARATIONS EFFECTIVE ON: 11/02/2022 2201 4th Avenue North Birmingham, AL 35203

CURRENT POLICY PERIOD. POLICY IS EFFECTIVE AT THE ADDRESS OF THE POLICY HOLDER AS STATED HEREIN
POLICY NUMBER:
10027375802 FROM: 08:01 PM 11/02/2022 TO: 12:01 AM 11/02/2023
STANDARD TIME

Sacha Padilla AUTO INSURANCE SPECIALISTS PRODUCER NUMBER

5505913
18538 NORDHOFF ST 16969 Von Karman Ave Ste 100
NORTHRIDGE, CA 91324 Irvine, CA 92606-4937 TELEPHONE NO.
(800) 493-7879

DESCRIPTION OF OWNED AUTOMOBILE

VEH USE YEAR MAKE, MODEL, BODY VEHICLE IDENTIFICATION DRV PTS RATE ZIP
NUMBER (VIN)
1 Pleasure 2004 TOYOTA CAMRY LE/SE/XLE 4DR SEDAN JTDBE32K340279900 1 0 91324

INSURANCE IS AFFORDED ONLY FOR THE COVERAGES FOR WHICH LIMITS OF LIABILITY AND PREMIUM CHARGES ARE INDICATED.

COVERAGES AND LIMITS OF LIABILITY PER PERSON PER ACCIDENT VEH 1

Bodily Injury $15,000 each person $30,000 each accident 616
Property Damage $10,000 each accident 641
Uninsured Motorist Bodily Injury ****REJECTED**** ****REJECTED**** No Cov

Total Premium For Each Car $1,257

CA Fraud Fee $1.76
Processing Fee $20.00

THIS POLICY PROVIDES REDUCED LIABILITY LIMITS WHEN AN INSURED AUTO IS BEING OPERATED BY A PERMISSIVE DRIVER
AS DEFINED WITHIN THE POLICY. LIABILITY LIMITS DROP TO THE MINIMUM STATUTORY LIMITS WHICH ARE $15,000 PER PERSON,
$30,000 PER ACCIDENT, AND $5,000 FOR PROPERTY DAMAGE IN CALIFORNIA.

ENDORSEMENTS: 104AMDE01; 00067R1017; 03333R1017; 10463ARN08; 03486R0110; 02540R0510; 01213R1004;

01412R0215

TOTAL PREMIUM FEES CASH APPLIED ---------------PAYMENTS--------------- 1ST PAYMENT DATE

$1,257.00 $21.76 $128.61 11 @ $110.56 12/02/2022

COUNTERSIGNED AT BY
67D04 11/02/2022 1 - 02 RSVP INSURED COPY