National Insurance Underwriters: 800 Yamato Road #100, Boca Raton, FL (Company Use Only)

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1 HOME STATE COUNTY MUTUAL INSURANCE COMPANY Knoll Trail, Ste 110 Dallas, TX TEXAS PERSONAL AUTO PROGRAM INSURANCE APPLICATION HSCTX Serviced By: National Insurance Underwriters: 800 Yamato Road #100, Boca Raton, FL (Company Use Only) Policy Effective Date Policy Expiration Date PRODUCER # Binder Number (MM/DD/YY) Time (MM/DD/YY) Time /05/17 12:01 AM 01/05/18 12:01 AM Applicant / Named Insured: ALVARO MORA FERNANDEZ Street Address: 1200 SUNRISE RD, 1306 City: ROUND ROCK St: TX County: WILLIAMSON Zip: Phone: (H) Cell Phone Number: Employer's Name & Address: SELF Address Important: Everyone who owns a vehicle on this application must be listed as a Named Insured, an Additional Interest, a Listed Driver or an Excluded Driver. List every person living with you who is age fifteen (15) or older. These people must be listed even if they do not have a driver's license. They must be listed even if they have their own insurance. List any other person who regularly uses any listed vehicle, even if that person does not live with you. Resident/ Driver # Excluded (Y or N) Full Name Sex Date of Birth As Shown on License (MM/DD/YY) Marital Status Miles One Way SR 22 Case # Driver's License No. State Occupation N ALVARO MORA FERNANDEZ M 02/19/70 M TX CONSTRUCTION STATEMENT OF ALL CONVICTIONS FOR TRAFFIC VIOLATIONS Driver # List ALL convictions & accidents in the past thirty-six (36) Months for everyone who is NOT excluded. Date of Driver No. Date of Accident/Violation Type of Violation Involved Accident/Violation Type of Violation TX-HSCMIC-APP Page 1 of 5 Ed

2 VEHICLE DESCRIPTION / VEHICLE USE Driver Veh # Year Make Model Body Type Sym Vehicle Identification # Rated VIN Ter Cls Pts Use # 1 02 HOND ACCORD SEDAN 4D 13 1HGCG56602A HGCG566&2 18 MM47 0 P HOME STATE COUNTY MUTUAL INSURANCE COMPANY Applicant Registered to Auto? Y Veh # 1 2 Name LIENHOLDER Address 3 4 Veh # Name ADDITIONAL INTEREST Address Veh # 1 2 COVERAGES BI Liability PD UM/UIM BI Liability Other Than PerPerson/PerOcc Liability UMPD PerPerson/PerOcc Deductible Collision 30/60 25 $0 Collision Deductible $0 PIP PerPerson Road Service N 3 4 Veh # Liability UM/UIM PREMIUM Liability UMPD Other than Coll Collision PIP Road Serv 1 $192 $0 $ PREMIUM TOTALS Total Premium $ TX-HSCMIC-APP Page 2 of 5 Ed

3 HOME STATE COUNTY MUTUAL INSURANCE COMPANY Applicant MUST answer all questions. Provide explanations in the Comments section below 1. Does anyone listed on this application reside outside of Texas more than 2 months per year? Y N X (If Yes, driver must be excluded. See Rule Guide for Military Exception.) 2. Does anyone listed on this application have any medical, mental or physical condition(s) that would impair the ability to drive safely? This includes seizures, convulsions, blackouts, loss of consciousness, or other conditions. Y N X (If Yes, explain in the Comments section below & provide medical clearance certificate.) 3. Is any listed vehicle used: to transport people in exchange for a fee; to carry explosives or flammable items for a fee; or for any other business purpose? Y N X (If Yes, you are not eligible for this policy.) 4. Have you listed everyone living with you who is age fifteen (15) or over? Have you listed everyone else who operates any listed vehicle on a regular or infrequent basis? This includes children living away from home. Y N X (If No, list them on page 1, and provide an explanation in the Comments section below.) 5. Has any listed vehicle: been titled as salvage, declared a total loss, or is any covered vehicle a gray market vehicle? A gray-market vehicle is a vehicle imported into the United States through channels other than a manufacturer's authorized U.S. distributor. Y N X (If Yes, vehicle is not eligible for physical damage coverage.) 6. Is any listed vehicle a dune buggy, custom/kit car vehicle, replica vehicle, custom built, limited production, antique or classic vehicle? Y N X (if Yes, vehicle is not acceptable) 7. Are all listed vehicles registered in Texas? X Y N (If No, list vehicle under "comments." Vehicle must be registered in Texas within 30 days. 8. Is every vehicle listed registered to the applicant? X Y N (If No, identify the vehicle and registrant in the "Comments" section below). 9. Are all vehicles listed garaged at address provided? X Y N (If No, list vehicle under "comments.") 10. Is any listed vehicle regularly used in Mexico? Y X N If Yes, explain under comments below and indicate frequency of usage in Mexico. Comments: APPLICANT'S STATEMENT: I have reviewed this application. I understood all of the questions, and I gave all of the information to the agent. All of the information that I have provided is true and correct. These statements are my representations. They are offered to the Company as an inducement to provide me with this insurance. I agree that, in accordance with Texas insurance code chapter 705, this policy or any renewal may be void from inception if I provided any material fact that is false or misleading information. I understand that the Company may reject this application or charge additional premiums if I have provided any false or misleading information. I understand that during the first 60 days after policy inception, or at renewal, the Company may adjust the premium to reflect my driving record. I agree that this application does not bind me to accept the insurance nor the Company to accept the risk. I authorize the Company to order the driving record, or other reports, of anyone listed on this policy. I agree that the Company may charge the correct rate based upon the findings. If the down payment is not honored by my financial institution, I agree that the policy is void from inception and I will have no coverage. I understand that my policy will be cancelled if the correct premium is not paid. I authorize the Company to inquire as to the character, reputation, personal characteristics, and mode of living of anyone listed on this policy. I agree to pay any additional premium that is charged based upon information discovered. I understand that I may contact the Company to access this information and correct anything that is wrong. I agree to be charged the following fees. I agree that fees may change at renewal of this policy. I understand that if the Company changes any fees, I will be notified at the time of the renewal offer. I agree to pay all fees assessed under this policy. I understand that my failure to pay any fee may result in policy cancellation for non-payment of premium, or the assessment of additional fees. Fee Type One Month Policy Six Month Policy Policy Fee $12.00 $60.00 Physical Damage Policy Fee $3.00 $15.00 SR-22 $5.00 $25.00 Installment Fee (non-ach) N/A $10.00 Installment Fee (ACH) N/A $5.00 TX-HSCMIC-APP Page 3 of 5 Ed

4 HOME STATE COUNTY MUTUAL INSURANCE COMPANY Fee Type One Month Policy Six Month Policy Late Fee N/A $10.00 Returned Check Fee N/A $35.00 Cancellation Fee (Insured Request) $20.00 $20.00 Auto Theft Prevention $0.16 per vehicle $1.00 per vehicle ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. THE COMPANY HAS A ZERO TOLERANCE POLICY FOR FRAUDULENT ACTIVITY. WE ACTIVELY INVESTIGATE AND PURSUE PROSECUTION OF PERSONS WHO COMMIT INSURANCE FRAUD. IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. I understand that this application will become a part of my policy. I understand that coverage is not effective until the application is bound by my agent on the Company system, signed by me, and the premium paid. I received a copy of this application along with its attachments, and my policy contract. X Signature of Applicant / Named Insured Date PRODUCER STATEMENT I the undersigned do hereby warrant, certify and affirm that the information contained in this application was provided by the applicant, that I have accurately recorded the information provided by the applicant, that the application was signed by the applicant, and that a copy of this application along with its attachments and the policy contract have been provided to the applicant. X Signature of Producer Date NON-BUSINESS USE I hereby state that I do not use any vehicle on this policy for any business use other than travel to and from my normal workplace. X Signature of Applicant / Named Insured Date PHOTOS FOR PHYSICAL DAMAGE COVERAGE I hereby acknowledge that the Company requires photographs of any vehicle for which Collision and Other Than Collision coverages are requested. I agree to make all such vehicles available to my agent within ten calendar days of the date of this application. I further understand that the Company will cancel my Collision and Other Than Collision coverage on any vehicle which has not been photographed within 10 calendar days of this application.. X Signature of Applicant / Named Insured Date PERSONAL INJURY PROTECTION (PIP) WAIVER You have the legal right to purchase Personal Injury Protection (PIP) coverage. This coverage provides you, your family and your passengers with up to two thousand five hundred dollars ($2,500) in compensation for medical expenses, costs of hiring a caregiver, and/or eighty percent (80%) of lost income of an injured person. This coverage applies regardless of who caused the accident. X I hereby reject Personal Injury Protection (PIP) Coverage for this policy and renewal thereof. OR I elect Personal Injury Protection (PIP) Coverage. X Signature of Applicant / Named Insured Date Page 4 of 5

5 UNINSURED OR UNDERINSURED MOTORIST COVERAGE Insurance companies are required to provide Uninsured or Underinsured Motorist Coverage in an amount equal to the coverage limits of the policy s bodily injury and property damage liability coverage. This coverage protects insureds who are legally entitled to recover from owners or operators of uninsured or underinsured motor vehicles damages for bodily injury, sickness, disease, or death, or property damage resulting from the ownership, maintenance or use of any uninsured motor vehicle. By making your selection below, you agree that your options for this coverage have been fully explained and understood, and that you have the right to reject this coverage in its entirety. Initial next to your selection: X I do hereby reject Uninsured or Underinsured Motorist Coverage entirely. OR HOME STATE COUNTY MUTUAL INSURANCE COMPANY I do hereby elect Uninsured or Underinsured Motorist Coverage at the following limits: $30,000 per person / $60,000 per accident for Bodily Injury $25,000 Property Damage (Note: $250 deductible applies to each claim) X Signature of Applicant / Named Insured Date HOME STATE COUNTY MUTUAL PROXY I hereby appoint the President and Secretary of Home State Insurance Group, or either of them, or their successors in office, with full power in either to appoint or substitute, to be the undersigned's lawful proxy and attorney in fact, and said attorney is hereby authorized and empowered to attend any policyholder meetings, or any adjournment or adjournments thereof, and to represent, vote and otherwise act for the undersigned in the same manner and with the effect as if the undersigned were personally present. This proxy shall continue in force for the full period of the policy and any renewal thereof, unless sooner revoked in writing and shall be irrevocable for the full period permitted by law. I agree to be governed by the provisions of Chapter 912 of the Texas Insurance Code. X Signature of Applicant / Named Insured Date TX-HSCMIC-APP Page 5 of 5 Ed

6 HOME STATE COUNTY MUTUAL INSURANCE COMPANY Administered by National Insurance Underwriters Texas Personal Auto Policy Limitation Disclosure I understand that the policy I am obtaining contains coverage that is more limited than the Texas Standard Personal Auto Policy. Disclosures related to Your Texas Personal Auto Policy-PLEASE READ CAREFULLY: Criminal or Intentional Acts Endorsement: Initial There is no coverage for bodily injury, property damage, or damage to your covered auto Contractual Liability Exclusion: Initial We do not provide liability coverage for bodily injury or property damage assumed by or imposed on any covered person under any agreement, contract or bailment. See Contractual Liability Endorsement CL.HSCM.2006 Misrepresentation of Fraud Endorsement: Initial

7 Newly Acquired Auto Endorsement: Initial Coverage for a newly acquired auto that replaces a vehicle shown in the Declarations will have the same coverage we now provide for the vehicle being replaced. You must notify us of the replacement vehicle within 20 days only if you wish to add or continue Coverage for Damage to Your Auto. Coverage for a newly acquired auto that is acquired in addition to the vehicles listed on the Declarations will have the broadest coverage we now provide for any auto shown in the Declarations provided that you notify us within 20 days of the date you become the owner. See YCA.HSCM.2013 Physical Damage Limitations: Initial Other Than Collision (Comprehensive) Coverage is limited to the following perils: Theft/Larceny; Earthquake; Windstorm; Hail/Water/Flood; Vandalism/Malicious Mischief; Riot/Civil Commotion; Fire/Lightning/Explosion; Contact with bird/animal; Breakage of glass. The policy changes and limitations stated above have been fully explained to me by: (agent name). X Signature of Applicant/Named Insured (required) X Signature of Agent (required) Date Date TX.HS.LIMDISC

8 Electronic Mail Acknowledgement I the undersigned, hereby authorize the Company to provide my auto policy documents via electronic mail. All such documents will be sent to the address provided on my application. I hereby acknowledge that this is the only means by which these documents will be provided to me; additionally, I agree to notify the Company promptly if I change my address. Print Name X Signature of Applicant/Policyholder Date TX.HS.EML

9 Notification of Privacy Policy and Practices At Home State, We Take Your Privacy Seriously As a valued customer, you are very important to us. In order to insure you and your family, we need to have certain information about you, but please be assured that: we are committed to protecting your privacy. We keep your information secure and confidential, and safeguard it in many ways. This notice explains the kinds of information we keep, how we protect it, and who may see it. WHAT KIND OF INFORMATION WE HAVE AND WHERE WE GET IT: You provide us with most of the information we need as part of the insurance application process. We may also request reports from various consumer reporting agencies in connection with your application for insurance and/or any renewal of such insurance. The kind of information we may gather depends upon the type of policy, but may include automobile motor vehicle reports, claim reports, credit reports and inspections. We may also receive and verify other information from government agencies or independent reporting companies to help us correctly rate and properly underwrite your insurance risk. Once you re insured with us, your file may also contain information connected with any claims you ve had. The claim representative may comment, for example, on the condition of your insured property or let us know if there have been any changes in the way it s used. We may also keep a police report if there was one in connection with an accident. We also may require some medical information about an insured if, for example, we need to know whether a physical impairment will affect a person s ability to drive safely. However, we do not share medical information we collect about you internally or externally for any purpose except the following: underwriting insurance; administrating your policy, account, or claim; as required or permitted by law; or as otherwise authorized by you WHO HAS ACCESS TO THIS INFORMATION: Information collected about you which we keep, will be contained in our policy and claim records. We restrict access to your personal information only to employees who need it to issue and service your insurance coverage and to settle claims. Except as described below, we will not disclose information about you without your authorization. We may, without your prior permission and only if permitted by law, provide information about you contained in our records and files to certain persons or organizations such as: your independent agent or broker; our affiliated insurance companies or our reinsurers; an independent claim adjuster or investigator; persons or organizations that conduct scientific research including actuarial or underwriting studies; or an insurance support organization or another insurer, to prevent or prosecute fraud or to properly underwrite the risk. Also, on rare occasions, we may be required to share this information: with a State Insurance Department or other governmental/agency if required by federal, state or local laws; if ordered by a summons, court order, search warrant or subpoena; or to protect our own legal interests, or in case of suspected fraud or other illegal activities. We may share the information we collect, as described above, with companies that perform marketing services on our behalf and with whom we have joint marketing or servicing agreements. We assure you, however, that we will not sell your information to anyone. We do not reveal information about our customers or former customers to anyone except as permitted by law. This privacy statement describes our privacy practices for both current and former customers. We will provide one copy of this notice to joint or contract holders. Please share this information with everyone covered by your policy or contract. Upon your request, we will send additional copies of this statement. Home State County Mutual Insurance Company Waco, Texas

10 IMPORTANT NOTICE To obtain information or make a complaint: You may contact your Managing General Agent at extension 507. You may call Home State County Mutual s toll free telephone number for information or to make a complaint at You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at You may write the Texas Department of Insurance: P.O. Box Austin, TX Fax: (512) consumerprotection@tdi.texas.gov To obtain price and policy form comparisons and other information relating to residential property insurance and personal automobile insurance, you may visit the Texas Department of Insurance/Office of Public Insurance Counsel website at PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact the agent or the company first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY This notice is for information only and does not become a part or condition of the attached document. Para obtener información o para presentar una queja: AVISO IMPORTANTE Usted puede comunicarse con su agente general al ( extensión 507). Usted puede llamar al numero de teléfono gratuito de Home State County Mutuals' para obtener información o para presentar una queja al Usted puede comunicarse con el Departamento de Seguros de Texas para obtener información sobre compaginas. Coberturas, derechos, o quejas al Usted puede escribir al Departamento de Seguros de Texas a: P.O. Box Austin, TX Fax: (512) Sitio web: ConsumerProtection@tdi.texas.gov Para obtener formas para la comparación de precios y pólizas y para obtener información sobre el seguro de propiedad residencial y de seguro de automóvil personal, visite el sitio web del Departamento de Seguros de Texas/Oficia del Asesor Publico de Seguros: DISPUTAS POR PRIMAS DE SEGUROS O RECLAMACIONES: Si tiene una disputa relacionada con su prima de seguro o con una reclamación, usted debe comunicarse con el agente o la compagina primero. Si la disputa no es resuelta, usted puede comunicarse con el Departamento de Seguros de Texas. ADJUNTE ESTE AVISO A SU POLIZA: Este aviso es solamente para propósitos informativos y no se convierte en parta o en condición del documento adjunto.

11 IMPORTANT NOTICE NON-RENEWALS FOR NOT-AT FAULT ACCIDENTS OR CLAIMS (28 TAC ) We may not use any of the following types of accidents or claims as the only reason for refusing to renew your personal auto policy: 1. a claim involving damage from a weather-related incident that does not involve a collision (some examples being hail, flood, tornado, winds or hurricanes); 2. an accident or claim involving damage by contact with an animal or fowl; 3. an accident or claim involving damage caused by flying gravel, missiles or falling objects; however, if you have three of these losses in any 36-month period, we may increase your deductible to the higher of $250 or the next available deductible increment higher than your present deductible amount, at your renewal date; 4. a claim under towing and labor protection; however, if you have four claims of this type in any 36-month period, we have the option of eliminating this coverage from your policy; 5. any other not-at-fault accident or claim unless there are two or more of these accidents or claims in any 12-month period. Refusal to renew means our refusal to renew your personal auto policy in the same company which originally issued the policy. To the extent of any possible conflict between this notice and the Texas Administrative Code (28 TAC ), the latter will be controlling. NOTICE: The Automobile Burglary and Theft Prevention Authority fee is payable in addition to the premium due under this policy. This fee partially or completely reimburses the insurer, as permitted by 28 TAC 5.205, for the $2.00 fee per motor vehicle year required to be paid to the Automobile Burglary and Theft Prevention Authority under Vernon s Annotated Revised Civil Statutes of the State of Texas, Article 4413(37), 10, which was effective on June 6, 1991, and revised effective September 1, 2011.

12 COVERAGE PROVIDED BY: HOME STATE COUNTY MUTUAL INSURANCE COMPANY ADMINISTERED BY: National Insurance Underwriters: 800 Yamato Road #100, Boca Raton, FL PROCESS DATE: 07/05/17 POLICY PERIOD DECLARATIONS POLICY NUMBER FROM: 07/05/17 TO: 01/05/18 HSCTX PRIVATE PASSENGER AUTOMOBILE POLICY WHEN ATTACHED TO THE PRIVATE PASSENGER AUTOMOBILE POLICY, THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY ACCORDING TO OUR RECORDS. NOTE: Company will consider your claims history for purposes of determining whether to refuse to renew your policy. The Automobile Burglary and Theft Prevention Authority fee is payable in addition to the premium due under this policy. This fee partially or completely reimburses the insurer, as permitted by 28 TAC 5.205, for the $2.00 fee per motor vehicle year required to be paid to the Automobile Burglary and Theft Prevention Authority under Vernon s Annotated Revised Civil Statutes of the State of Texas, Article 4413(37), 10, which was effective on June 6, 1991, and revised effective September 1, INSURED NAME AND ADDRESS PRODUCER # PHONE # ALVARO MORA FERNANDEZ 1200 SUNRISE RD, 1306 ROUND ROCK, TX COVERAGES BODILY INJURY PROPERTY DAMAGE PERSONAL INJURY PROTECTION UMPD UNINSURED MOTORIST OTHER THAN COLLISION COLLISION ROAD SERVICE ENDORSEMENT SR-22 FILING BURGLARY & THEFT PREVENTION FEE POLICY FEE / LIABILITY POLICY FEE / PHYSICAL DAMAGE APPLIED DISCOUNT: EXCLUDED DRIVERS: 3YR LIMIT OF LIABILITY PO BOX $30, EACH PERSON $60, EACH ACCIDENT $25, EACH ACCIDENT EACH PERSON EACH ACCIDENT DEDUCTIBLE: EACH PERSON EACH ACCIDENT CAR 1 ACTUAL CASH VALUE LESS DEDUCTIBLE (Max $40,000) ( ) BASIC ( ) DELUXE ( ) PREMIER REMCO / AMCO INSURANCE AUSTIN, TX TOTAL CARS ON THIS PAGE >>> CAR 1 $ $90.00 PREMIUM (IN DOLLARS) $1.00 $60.00 $0.00 $ TOTAL TERM PREMIUM >>> POLICY TOTAL >>> $ $ DESCRIPTION OF CARS CAR YEAR TRADE NAME MODEL BODY STYLE SYM/TYPE VEHICLE ID NUMBER TERR TYPE OF USE ZIP 1 02 HOND ACCORD SEDAN 4D 13 1HGCG56602A Pleasure LOSS PAYEE/ADDITIONAL INTEREST NAME AND ADDRESS CAR LP or AI NAME ADDRESS COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT ARE SHOWN FOR THE COVERAGE DRIVER NAME D.O.B POINTS STATE LICENSE NUMBER CLASS SR-22 CASE # 1 ALVARO MORA FERNANDEZ 02/19/70 0 TX MM47 ENDORSEMENTS APPLICABLE: ENDORSEMENTS APPLICABLE COUNTERSIGNED BY COUNTERSIGNED DATE: Authorized Representative TX-HSCMIC-DEC INSURED COPY Page 1 of 1 Ed

13 Prescribed Auto ID Card Form 28 TAC SIDE A (ENGLISH) SIDE A (SPANISH) Texas Liability Insurance Card Tarjeta de Seguro de Responsabilidad Civil de Texas Name and Address of Insured Nombre y Dirección del Asegurado ALVARO MORA FERNANDEZ ALVARO MORA FERNANDEZ 1200 SUNRISE RD, SUNRISE RD, 1306 ROUND ROCK, TX ROUND ROCK, TX Insurance Company & Toll-Free Number Compañía de Seguros Home State County Mutual Insurance Company Home State County Mutual Insurance Company Knoll Trail, Ste Knoll Trail, Ste 110 ROUND ROCK, TX ROUND ROCK, TX Agent & Phone Number Agente REMCO / AMCO INSURANCE REMCO / AMCO INSURANCE PO BOX PO BOX AUSTIN, TX AUSTIN, TX Policy Number Effective Date Expiration Date Número de la Póliza Fecha de Efectividad de la Póliza Fecha de Vencimiento de la Póliza HSCTX /05/17 01/05/18 HSCTX /05/17 01/05/18 Covered Vehicles (Year, Make & Model, VIN) 02 HOND ACCORD 1HGCG56602A This policy provides at least the minimum amounts of liability insurance required by the Texas Motor Vehicle Safe Responsibility Act for the specified vehicles and named insured and may provide coverage for other persons and vehicles as provided by the insurance policy. Vehículos con Cobertura (Año, Marca, Modelo, y VIN) 02 HOND ACCORD 1HGCG56602A Esta póliza provee por lo menos las cantidades mínimas de seguro de responsabilidad civil que que es requerida por la ley de responsabilidad para la sebguridad de los vehículos motorizados de texas (Texas Motor Vehicle Safety Responsibility Act, por su nombre en inglés) para los vehículos especificados y para los asegurados nombrados y puede proveer una cobertura para otras personas y vehículos segun los proporcionado en la póliza de seguro. PC418 Eff. 04/01/14 1/2

14 SIDE B (ENGLISH) SIDE B (SPANISH) Texas Liability Insurance Card Keep this card. IMPORTANT: You must show this card or a copy of your insurance policy when you apply for or renew your: Motor vehicle registration Driver's license Motor vehicle safety inspection sticker. You also may be asked to show this card or your policy if you have an accident or if a peace officer asks to see it. All drivers in Texas must carry liability insurance on their vehicles or otherwise meet legal requirements for financial responsibility. If you do not meet your financial responsibility requirements, you could be fined up to $1,000, your driver s license and motor vehicle registration could be suspended, and your vehicle could be impounded for up to 180 days (at a cost of $15 per day). [.If insurer provides a card in English only, include:] IMPORTANTE: Si usted desea una tarjeta oficial escrita en español, comuníquese con su agente de seguros a este número de teléfono [o dirección de correo electrónico]: Tarjeta de Seguro de Responsabilidad Civil de Texas Guarde esta tarjeta. IMPORTANTE: Usted debe mostrar esta tarjeta o una copia de su póliza de seguro cuando solicite o renueve su: Registro del vehiculo motorizado Licencia de conducir Etiqueta de inspección de segurida para su vehículo. También se puede pedir que usted muestre esta tarjeta o su póliza si tiene un accidente o si se la pide un oficial de policía. Todos los conductores en Texas deben tener un seguro de responsabilidad civil para sus vehículos, o de lo contrario deben cumplir con los requisitos legales de responsabilidad financiera. Si usted no cumple con los requisitos de responsabilidad financiera, podría estar sujeto a pagar una multa de hasta $1,000, más la suspensión de su licencia de conducir y la suspension del registro del vehículo, y además su vehículo podría ser confiscado por hasta 180 días (a un costo de $15 por día). (Insurer or Agent) ( optional) PC418 Eff 04/01/14 2/2

15 Down Payment Receipt and Billing Plan ALVARO MORA FERNANDEZ 1200 SUNRISE RD, 1306 ROUND ROCK, TX REMCO / AMCO INSURANCE PO BOX AUSTIN, TX Policy Number: HSCTX Billing Account Number: Effective Date: 07/05/17 Down Payment amount due: $43.00 (Agent acct) Payment Option: Monthly Payment Mode: Bill Insured via Mail