This document is an archive-only document which was not distributed to the insured.

CSAA Insurance Exchange

P.O.Box 22221
Automobile Policy Declarations
Oakland, CA 94623-2221 Please keep with your policy. See Important Notice on reverse.
For questions or changes call: 800.922.8228
Page 1 of 1

1. Name and Address of Insured

Declarations Process

POLICY INFORMATION
Type Amended Declarations Date 01-27-2023
LINDA VALDERRAMA
Policy Insured
MARYHELEN M VALDERRAMA Number CAAS100540856 Since 2004
ROBERT VALDERRAMA From 12:01 A.M. Standard Time at the address of the
3164 DOVELA WAY Named Insured, but not prior to the time applied
Your for or, if this is a replacement declarations, not
SAN JOSE, CA 95118-1020 Policy
01-21-2023 prior to the time coverage change was requested.
Period
To 12:01 A.M. Standard Time at the address of the
04-19-2023 Named Insured.

Alternate Address Occupation Alternate Number Telephone Number

Homemaker (408) 225-3618 (408) 225-3618

 Item Make Model Yr Body Type Vehicle Identification No. Name ADB?*
Drivers
1 FORD 1966 2 DOOR 6R07C154870 MARYHELEN Y
VEHICLES

DRIVERS
do not
2 ACURA 2005 HATCHBACK 2 DOOR JH4DC54855S010894 necessarily ROBERT Y
correspond
3 MERCEDES-BENZ 2022 SUV W1N4M4GBXNW169170 to principally Matthew N
operated
4 INFINITI 2011 SEDAN 4 DOOR JN1CV6AP8BM509216 vehicles. LINDA Y
Liability Limits Item 1 Item 2 Item 3 Item 4
Coverage
Each Person Each Occurrence Deductible Premium Deductible Premium Deductible Premium Deductible Premium

Bodily Injury 500,000 500,000 $81 $254 $181 $34

Medical Payments No Coverage No Coverage No Coverage No Coverage No Coverage

Uninsured Motorists 100,000 300,000 $33 $67 $49 $13

Uninsured Motorist
0 NO COV NO COV NO COV NO COV
Property Damage
Property Damage 500,000 $61 $452 $384 $57
Comprehensive     Actual Cash Value Less Deductible
COVERAGES/PREMIUMS

100 $47 100 $168 100 $307 100 $33

  Full Comprehensive Safety Glass Endorsement
          ($0 deductible) NO COV NO COV INCL NO COV
Collision               Actual Cash Value Less Deductible 500 500 500 500
  $137   $723   $1,006   $159
  Collision Deductible Waiver INCL INCL INCL INCL
Enhanced Transportation Expense
INCL $32 $32 $8
      $30 per day/$900 aggregate
All Risks                Actual Cash Value Less Deductible No Coverage No Coverage No Coverage No Coverage

Vehicle Loan/Lease Protection Endorsement No Coverage No Coverage No Coverage No Coverage

New Car Added Protection Endorsement No Coverage No Coverage No Coverage No Coverage

Original Equipment Manufacturer Parts (OEM) Endorsement No Coverage No Coverage $132 No Coverage

Ride-sharing Coverage Endorsement No Coverage No Coverage No Coverage No Coverage

               TOTAL PREMIUM PER VEHICLE   $359 $1,696 $2,091 $304

Premium 
* Automobile Death Benefits $15,000 per deceased insured person $6 
Premium Summary
This is not a bill.
CA Surcharge: $0

Total Additional Premium:        $304.00

Total Premium shown is for the Member AdvantageTM Program.
EXCLUSIONS
There is no coverage provided by this Policy while the following individual(s) operate a motor vehicle:
None
Schedule of Changes
Other Premium Bearing : Express: Add Vehicle
CHANGES

55 1500 12 15
(Continued on back)
 This document is an archive-only document which was not distributed to the insured.

Item Rated Driver Driv Safety Record Yrs Driv Exp Est Ann Mi Driven Veh Garage Zip Vehicle Usage Marital
DISCOUNTS/MESSAGES

1 Undesignated 1000 Mi 95123 Pleasure

See final page
2 Matthew Valderama 0 Pt 4 6320 Mi 95123 Commute S for explanation
3 MARYHELEN VALDERRAMA 1 Pt 35 8000 Mi 95123 Commute M of codes.

4 ROBERT VALDERRAMA 0 Pt 38 15000 Mi 95123 Pleasure M

Discounts:
Mature Driver: None. Multi Car: Item(s) 2, 3, 4.
Good Driver: Item(s) 1, 2, 3, 4. New Driver: None.
Multi Policy Home: Item(s) 1, 2, 3, 4. Good Student: None.

You may qualify for other products

LOSS PAYEE(S)

and discounts. For more info call

your Insurance Agent
House Agent San Jose Oakridge
(800) 922-8228

IMPORTANT NOTICE: THIS IS A PART OF YOUR DECLARATIONS

The insurance afforded is only with respect to such of the preceding coverages as are indicated by specific premium charge or charges.
The limit of the Exchange's liability under each such coverage shall be as stated herein, subject to all the terms of the policy. The purpose
for which the automobile is to be used is pleasure or business, subject to the exclusions in the policy, including the exclusion for
wholesale and retail delivery.
RENEWAL CERTIFICATE - Extends this policy for the period shown under Policy Period upon payment of the premium.
AMENDED DECLARATIONS - In consideration of the premium adjustment indicated herein this policy is hereby amended only with
respect to such changes as are indicated in the schedule of changes. The limit of the Exchange's liability under such amended coverage
shall be as stated herein.
LOSS PAYEE(S) - Any loss under Physical Damage coverages is payable as interest may appear to the named insured and the Loss Payee in
accordance with the loss payable agreement.
For your protection, California law requires that you be made aware of the following: Any person who knowingly presents false or
fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.

RATING INFORMATION DISCLOSURE EXPLANATION

 

(From Discounts/Messages Section on Previous Page)

ITEM (ITEM NUMBER): Item number is the number assigned to the vehicle shown on the Declarations.
RATED DRIVER: The driver assigned to a vehicle whose attributes (e.g., years driving experience, driving safety record and marital status) are used
to develop the premium.
DRIV SAFETY RECORD (DRIVING SAFETY RECORD): The total number of points assessed the driver for "principally at fault chargeable
accidents" with or without injury and/or vehicle code violation convictions (tickets). A "principally at fault chargeable accident" occurs
when the driver of a vehicle is at least 51% at fault for an accident and the total monetary damages (whether paid or not) in the
accident exceed:
● $750 or the accident resulted in death for losses occurring prior to 12/11/11
● $1,000 or the accident resulted in death for losses occurring 12/11/2011 or after
Additional information on the number and types of incidents can be provided on request. Carriers use different point count systems for
rating purposes. The number of points shown on your declarations would not necessarily match the number of points assigned by
another carrier.
YRS DRIV EXP (YEARS DRIVING EXPERIENCE): The number of years a driver has been licensed to drive a motor vehicle anywhere in the
world. However, a driver must have at least 18 months current driving experience in the United States, U.S. Territories, or Canada,
before foreign country driving experience can be counted.
EST ANN MI DRIVEN (ESTIMATED ANNUAL MILES DRIVEN): The estimated number of total miles a vehicle will be driven in the coming year
VEH GARAGE ZIP (VEHICLE GARAGED ZIP CODE): The ZIP code of the location where the vehicle is garaged.
VEHICLE USAGE: Vehicles are assigned to one of five usage designations: Business Use, Work Commute, Farm Use, Farm Business Use
or Pleasure.
MARITAL (MARITAL STATUS): "M" stands for Married, and "S" stands for Single.
DISCOUNTS: A reduced rate applies for each Discount listed.

55 1500 12 15
This document is an archive-only document which was not distributed to the insured.
CSAA Insurance Exchange / NAIC # 15539 CSAA Insurance Exchange / NAIC # 15539
P.O.Box 22221, Oakland, CA 94623-2221 P.O.Box 22221, Oakland, CA 94623-2221
800.922.8228 800.922.8228

CA Insurance Identification Card CA Insurance Identification Card

NAMED INSURED POLICY # NAMED INSURED POLICY #
MARYHELEN M VALDERRAMA CAAS100540856 MARYHELEN M VALDERRAMA CAAS100540856
ROBERT VALDERRAMA ROBERT VALDERRAMA
EFFECTIVE DATE EFFECTIVE DATE
Apr 19, 2022 Apr 19, 2022

There may be other drivers EXPIRATION DATE There may be other drivers EXPIRATION DATE
listed on your policy. Apr 19, 2023 listed on your policy. Apr 19, 2023

KEEP THIS COPY IN YOUR VEHICLE KEEP THIS COPY IN YOUR VEHICLE Fold line

VEHICLE YEAR / MAKE / MODEL VEHICLE ID # VEHICLE YEAR / MAKE / MODEL VEHICLE ID #
1966 FORD MUSTANG 6R07C154870 1966 FORD MUSTANG 6R07C154870

This insurance complies with CVC §16056 or §16500.5 This insurance complies with CVC §16056 or §16500.5

IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMS ARE PAID.
AA10XX 05 20 AA10XX 05 20

CSAA Insurance Exchange / NAIC # 15539 CSAA Insurance Exchange / NAIC # 15539
P.O.Box 22221, Oakland, CA 94623-2221 P.O.Box 22221, Oakland, CA 94623-2221
800.922.8228 800.922.8228

CA Insurance Identification Card CA Insurance Identification Card

NAMED INSURED POLICY # NAMED INSURED POLICY #
MARYHELEN M VALDERRAMA CAAS100540856 MARYHELEN M VALDERRAMA CAAS100540856
ROBERT VALDERRAMA ROBERT VALDERRAMA
EFFECTIVE DATE EFFECTIVE DATE
Apr 19, 2022 Apr 19, 2022

There may be other drivers EXPIRATION DATE There may be other drivers EXPIRATION DATE
listed on your policy. Apr 19, 2023 listed on your policy. Apr 19, 2023

KEEP THIS COPY IN YOUR VEHICLE KEEP THIS COPY IN YOUR VEHICLE Fold line

VEHICLE YEAR / MAKE / MODEL VEHICLE ID # VEHICLE YEAR / MAKE / MODEL VEHICLE ID #
2005 ACUR RSX JH4DC54855S010894 2005 ACUR RSX JH4DC54855S010894

This insurance complies with CVC §16056 or §16500.5 This insurance complies with CVC §16056 or §16500.5

IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMS ARE PAID.
AA10XX 05 20 AA10XX 05 20

CSAA Insurance Exchange / NAIC # 15539 CSAA Insurance Exchange / NAIC # 15539
P.O.Box 22221, Oakland, CA 94623-2221 P.O.Box 22221, Oakland, CA 94623-2221
800.922.8228 800.922.8228

CA Insurance Identification Card CA Insurance Identification Card

NAMED INSURED POLICY # NAMED INSURED POLICY #
MARYHELEN M VALDERRAMA CAAS100540856 MARYHELEN M VALDERRAMA CAAS100540856
ROBERT VALDERRAMA ROBERT VALDERRAMA
EFFECTIVE DATE EFFECTIVE DATE
Apr 19, 2022 Apr 19, 2022

There may be other drivers EXPIRATION DATE There may be other drivers EXPIRATION DATE
listed on your policy. Apr 19, 2023 listed on your policy. Apr 19, 2023

KEEP THIS COPY IN YOUR VEHICLE KEEP THIS COPY IN YOUR VEHICLE Fold line

VEHICLE YEAR / MAKE / MODEL VEHICLE ID # VEHICLE YEAR / MAKE / MODEL VEHICLE ID #
2022 MERC GLB W1N4M4GBXNW169170 2022 MERC GLB W1N4M4GBXNW169170

This insurance complies with CVC §16056 or §16500.5 This insurance complies with CVC §16056 or §16500.5

IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMS ARE PAID.
AA10XX 05 20 AA10XX 05 20
This document is an archive-only document which was not distributed to the insured.
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
Fold line 800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
Fold line 800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
Fold line 800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
This document is an archive-only document which was not distributed to the insured.
CSAA Insurance Exchange / NAIC # 15539 CSAA Insurance Exchange / NAIC # 15539
P.O.Box 22221, Oakland, CA 94623-2221 P.O.Box 22221, Oakland, CA 94623-2221
800.922.8228 800.922.8228

CA Insurance Identification Card CA Insurance Identification Card

NAMED INSURED POLICY # NAMED INSURED POLICY #
MARYHELEN M VALDERRAMA CAAS100540856 MARYHELEN M VALDERRAMA CAAS100540856
ROBERT VALDERRAMA ROBERT VALDERRAMA
EFFECTIVE DATE EFFECTIVE DATE
Apr 19, 2022 Apr 19, 2022

There may be other drivers EXPIRATION DATE There may be other drivers EXPIRATION DATE
listed on your policy. Apr 19, 2023 listed on your policy. Apr 19, 2023

KEEP THIS COPY IN YOUR VEHICLE KEEP THIS COPY IN YOUR VEHICLE Fold line

VEHICLE YEAR / MAKE / MODEL VEHICLE ID # VEHICLE YEAR / MAKE / MODEL VEHICLE ID #
2011 INFI G37 JN1CV6AP8BM509216 2011 INFI G37 JN1CV6AP8BM509216

This insurance complies with CVC §16056 or §16500.5 This insurance complies with CVC §16056 or §16500.5

IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMS ARE PAID.
AA10XX 05 20 AA10XX 05 20

CSAA Insurance Exchange / NAIC # 15539 CSAA Insurance Exchange / NAIC # 15539
P.O.Box 22221, Oakland, CA 94623-2221 P.O.Box 22221, Oakland, CA 94623-2221
800.922.8228 800.922.8228

CA Insurance Identification Card CA Insurance Identification Card

NAMED INSURED POLICY # NAMED INSURED POLICY #

VOID EFFECTIVE DATE

EXPIRATION DATE
VOID EFFECTIVE DATE

EXPIRATION DATE

KEEP THIS COPY IN YOUR VEHICLE KEEP THIS COPY IN YOUR VEHICLE Fold line

VEHICLE YEAR / MAKE / MODEL VEHICLE ID # VEHICLE YEAR / MAKE / MODEL VEHICLE ID #

IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMS ARE PAID.
AA10XX 05 20 AA10XX 05 20

CSAA Insurance Exchange / NAIC # 15539 CSAA Insurance Exchange / NAIC # 15539
P.O.Box 22221, Oakland, CA 94623-2221 P.O.Box 22221, Oakland, CA 94623-2221
800.922.8228 800.922.8228

CA Insurance Identification Card CA Insurance Identification Card

NAMED INSURED POLICY # NAMED INSURED POLICY #

VOID EFFECTIVE DATE

EXPIRATION DATE
VOID EFFECTIVE DATE

EXPIRATION DATE

KEEP THIS COPY IN YOUR VEHICLE KEEP THIS COPY IN YOUR VEHICLE Fold line

VEHICLE YEAR / MAKE / MODEL VEHICLE ID # VEHICLE YEAR / MAKE / MODEL VEHICLE ID #

IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART IMPORTANT! THIS INSURANCE IDENTIFICATION CARD IS NOT PART
OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN OF YOUR POLICY AND IS VALID ONLY WHILE YOUR POLICY IS IN
FORCE AND YOUR PREMIUMS ARE PAID. FORCE AND YOUR PREMIUMS ARE PAID.
AA10XX 05 20 AA10XX 05 20
This document is an archive-only document which was not distributed to the insured.
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
Fold line 800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
Fold line 800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
Fold line 800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy
IF YOU HAVE AN ACCIDENT
1. Notify police immediately.
2. Write down names, addresses, telephone numbers,
and license numbers of persons involved and of
witnesses. Also write down or take a photo of the
license plate number and state of each vehicle.
3. Take photos of all damaged vehicles involved in
incident, and any other property damage (i.e. trees,
structures, etc.).
4. Report all accidents to AAA Claims immediately at
800.922.8228.
Sign in to MyPolicy to easily
start a claim online, anytime.
Sign in at:
csaa-insurance.aaa.com/MyPolicy