BRISTOL WEST INSURANCE COMPANY PO BOX 31029 INDEPENDENCE, INDEPENDENCE, OH 44131-0008 Inquire or pay your bil ontine using www:bristolwest.com . 1505587 ‘Named insured: NS GROUP ADOLFO URIAR GUERRERO BALLESTA TRGENCY INC 1868 N 24TH ST 5042 LAMAR AVE RANSAS CITT:KS 66100867 MISSION KS 66202-1741 Telephone: 913-384-6050 POLICY PREMIUM TOTAL § 1,166.00 [RENEWAL DECLARATION a ‘Upon payment ofthe required renewal premium, these coveraBes ‘become effective a the date and time listed above. A ae SR22 Birth Mar Sex License Number ne] Pesan 9 GUERRERO BALLESTA en oni M pmMORTE tr EDIMAR FAJARO DEL VALLE Ne N ooee SM ee y ks EFRIN J MARTINEZ KS-PCE-O1 (07715) 1010 (11/10) Vehicle Use: Pleasure ‘State: KS ‘Symbol: 0515~ O4UNX1 Year / Make / Model: 2003 NISS XTERRA XESE UT Vehicle Identification #: SNIED28T13C659532 Discounts: MULTL-CAR, GO PAPERLESS Location: 2003 NISS XTERRA XE 1868 24TH ST KANSAS CITY, KS 66104 oss Payee: NIA Additional Interest: N/A Garaging PerPerson Per Accident Limit Coverage ‘Limit Premium Deductible BODILY INJURY 50,000 100,000 229.00 PERSONAL INIURY PROTECTION 51.00 BASIC w/4,500 MEDICAL EXPENSE PROPERTY DAMAGE 50,000 256.00 UNINSURED / UNDERINSURED MOTORIST BODILY INJURY 50,000 100,000 68.00 on wuthorized Si 1 Anon ST Of 2 = Issued Date: 05/05/23 INSURED.