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2021/06/24 Jacob Green & AssociatesDocuSign Envelope ID: BE865753-E635-4190-947D-6C0D5F57D2EE PERSONAL AUTO POLICY DECLARATION THE FOLLOWING FEE(S) MAY APPLY: LATE:$5.00 PAYMENT RETURNED (NSF):$10.00 CANCEL:$50.00 INSTALLMENT BILL PLAN SERVICE CHARGE:$4.00 Authorized Company Representative (where required) Named Insured and Mailing Address JACOB GREEN 13161 BRITTANY WOODS DR TUSTIN, CA 92780-3911 E-mail: JSGREEN48@GMAIL.COM Vehicle(s) and Driver(s) Veh Year Make/Model Vehicle ID Number Use Vehicle Discounts/Comments Zip Mileage 1 13 HOND PILOT LX UT 5FNYF3H20DB022970 W MCD\GD 92780 16,500 2 16 HOND ODYSSEY EXL PV 5FNRL5H60GB064586 P MCD\GD\ATD 92780 8,000 Veh Rated Driver Years Licensed Tickets Chargeable Accidents Driver Discounts 1 JACOB GREEN 25 0 GDD\SD5 2 NICOLE GREEN 28 0 GDD\SD5 COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE Coverage Limit of Liability Veh 1 Veh 2 A.Bodily Injury Liability includes $0.88 per vehicle fraud fee $50,000 each person $100,000 each accident $ 197.00 $ 84.00 B.Property Damage Liability $25,000 each accident $ 127.00 $ 77.00 C.Medical Payments each person Uninsured Motorist D.Bodily Injury $50,000 each person $100,000 each accident $ 45.00 $ 38.00 DAMAGE TO YOUR VEHICLE Veh 1 Veh 2 Actual Cash Value Less Deductible Ded.Ded. E.Comprehensive $1,000 $1,000 $ 12.00 $ 12.00 F.Collision $1,000 $1,000 $ 93.00 $ 94.00 Uninsured Motorist D1.Property Damage DED WAIVE DED WAIVE $ 6.00 $ 6.00 21st Century G.Roadside Assistance $75 each disablement Included Included Rental H.Reimbursement Per day max Premium J.Additional Equipment The first $1000 is automatically included with coverage E or F. Additional coverage is optional. Included Additional Total $1,000 $1,000 $1,000 $1,000 $ 0.00 $ 0.00 Total Premium Per Vehicle $ 480.00 $ 311.00 If the installment bill plan is used, a service charge may apply.Total Premium $ 791.00 Endorsement(s)/Agreement(s) Applicable: FPN-CA (1/20)TCU-1 (01/19) TCU511CA (05/18)TCU531CA (02/12) AU CWF9 1011 Loss Payee (LP), Additional Insured (AI)Drivers Not Rated 04/29/21 WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. Visit 21st.com to make policy changes, pay your premium, and more. Register online today! For Customer Care call 800-241-1188. TCU41CA (12/14)21st Century Insurance Company, P.O. Box 15510, Wilmington, DE 19886-5292 RENEWAL EFFECTIVE 06/05/21 Account: INTERNET CUSTOMERS Customer Service Center: 21st CENTURY INSURANCE 21ST CENTURY PLAZA P.O. BOX 15510 WILMINGTON, DE 19850-5510 Policy No: 2216 67 88 Policy Period: From 06/05/21 To: 12/05/21 12:01 AM Standard Time DocuSign Envelope ID: BE865753-E635-4190-947D-6C0D5F57D2EE VEHICLE LOSS PAYABLE ENDORSEMENT (49-A) (REVISED JANUARY 22,2002) The Company hereby agrees as follows: Loss or damage under this policy shall be paid,as interest may appear,to you and the loss payee shown in the Declarations.This insurance with respect to the interest of the loss payee,shall not become invalid because of your fraudulent acts or omissions unless the loss results from your conversion,secretion or embezzlement of the insured vehicle.However, we reserve the right to cancel the policy as permitted by policy terms and the cancellation shall terminate this agreement as to the loss payee's interest. We will give the same advance notice of cancellation to the loss payee as we give to the named insured shown in the Declarations. When we pay the loss payee, we shall to the extent of payment, be subrogated to the loss payee's rights of recovery. This endorsement becomes part of the policy for which it is issued and supercedes and controls anything in the policy contrary hereto but is otherwise subject to the Declarations, insuring agreements, exclusions, and conditions thereof. ADDITIONAL INTERESTS ENDORSEMENT (TCE-2) It is agreed that THE ADDITIONAL INSURED NAMED IN THE DECLARATIONS is included as an additional insured under the policy pertaining to ownership,maintenance or use of the described vehicle while being operated by or on behalf of the named insured,but such inclusion of the additional interest or interests shall not operate to increase the limits of the company's liability. TO THE MORTGAGEE / ADDITIONAL INSURED UPON EXPIRATION ON THE POLICY TERM,THE POLICY WILL BE AUTOMATICALLY EXTENDED FOR ANOTHER TERM AND FOR SUBSEQUENT TERMS UPON PAYMENT OF THE REQUIRED RENEWAL PREMIUM.IF A RENEWAL PREMIUM IS NOT PAID,OR IF THE POLICY IS TERMINATED FOR ANY OTHER REASON, YOU WILL BE GIVEN 10 DAYS WRITTEN NOTICE NOTICE TO THE INSURED / PREMIUM INCREASE FOR ACCIDENTS AND TRAFFIC CONVICTIONS: You have the right to be informed, upon request, of any increase in your premium because of accidents or convictions for traffic violations. SAFETY RECORD NOTICE Your Safety Record is one factor which determines your premium using the number of minor violations,major violations and principally at-fault accidents (>=51%)which occurred during the three years immediately preceding the effective date or renewal date of the policy. ·Accident(s)on or after December 11,2011:An accident is chargeable if the driver is determined to be at least 51%of the legal cause and for which either the accident resulted in bodily injury or death or the total loss or damage for Property Damage liability and/or Collision coverage exceeds $1000. ·Accident(s)prior to December 11,2011:An accident is chargeable if the driver is determined to be at least 51%of the proximate cause and for which a payment is made that exceeds $750 for a bodily injury liability coverage, or there is a death, or $1000 for property damage liability or collision coverage. In order to verify the driving record used to determine an individual’s safety record points,the named insured must provide acceptable verification of the accident driving record for the prior three years for all operators rated on the policy. DocuSign Envelope ID: BE865753-E635-4190-947D-6C0D5F57D2EE COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 PRIMARY AND NONCONTRIBUTORY – OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. DocuSign Envelope ID: BE865753-E635-4190-947D-6C0D5F57D2EE COMMERCIAL GENERAL LIABILITY CG 20 33 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 33 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 ADDITIONAL INSURED – OWNERS, LESSEES OR CONTRACTORS – AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II – Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. DocuSign Envelope ID: BE865753-E635-4190-947D-6C0D5F57D2EE Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 33 04 13 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III – Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. DocuSign Envelope ID: BE865753-E635-4190-947D-6C0D5F57D2EE DocuSign Envelope ID: BE865753-E635-4190-947D-6C0D5F57D2EE