National Insurance Underwriters: 800 Yamato Road #100, Boca Raton, FL (Company Use Only) Select One of the Following Programs:

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1 OCCIDENTAL FIRE AND CASUALTY COMPANY OF NORTH CAROLINA P.O. Box Raleigh, NC COLORADO PERSONAL AUTO PROGRAM INSURANCE APPLICATION OFCCO 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 /05/15 12:01 AM 07/05/15 12:01 AM Applicant/First Named Insured: MANUELA I BONILLA SS# Street Address: 600 S DAYTON ST, B13 - City: AURORA St: CO County: ARAPAHOE Zip: Phone: (H) (C) Employer's Name & Address: SALES (W) Select One of the Following Programs: Primary X Program: Consists of coverage limits up to (50/100/50); credit scored OR non-credit scored; minimum deductible available of $100 for Comprehensive, Collision, and UMPD. Credit Scored? Yes No X Elite Program: Credit scoring required; available liability limits up to 100/300/50; minimum deductible available of $100 for Comprehensive, Collision, and UMPD; limited business/artisan use available. Important: Everyone who owns a vehicle on this application must be listed as a Named Insured or an Additional Named Insured. List every person living with you who is age 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 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 N MANUELA I BONILLA VICTOR M BECERRA F M 08/21/73 12/31/74 M M CO CO SALES SALES STATEMENT OF ALL CONVICTIONS FOR TRAFFIC VIOLATIONS Driver # List ALL convictions & accidents in the past 36 Months for everyone who is NOT excluded. Date of Accident/Violation Type of Violation Driver No. Involved Date of Accident/Violation Type of Violation CO-OCC-APP Page 1 of 5 Ed. (8-1-12)

2 Occidental Fire & Casualty Company of North Carolina Veh # Year Make 1 03 NSSN 2 02 CHEV 3 12 CHEV 4 Model MURANO SILVERADO CRUZE VEHICLE DESCRIPTION / VEHICLE USE Body Type Sym Vehicle Identification # Rated VIN UTL4X44D PKP4X24D SEDAN 4D JN8AZ08WX3W GCEC19V G1PK5SC4C JN8AZ08W&3 2GC&C19V&2 1G1PK5SC&C Custom Driver Equip($) Ter Cls Pts Use # MM40 0 P MF41 0 P MM Veh # Veh # LIENHOLDER Co Code Name Address ADDITIONAL NAMED INSURED Co Code Name Address AI AI AI COVERAGES Veh # BI Liability PerPerson/PerOcc PD Liability UM BI Liability PerPerson/PerOcc Med Pay Other than Coll Deductible Collision Deductible Custom Equip Deductible Snowplow Use Road Service Endt /50 25/50 25/ $5,000 $5,000 $5,000 $500 $500 $500 $500 $0 $500 $0 $500 $0 N N N Y Y Y 5 6 PREMIUM Veh # Liability UM Liab Med Pay Other than Coll Collision C/S Equip Road Serv Endt PREMIUM TOTALS $174 $166 $196 $34 $35 $45 $61 $45 $76 $155 $138 $217 $0 $0 $0 $80 Total Premium Total Remittance $1, $1, CO-OCC-APP Page 2 of 5 Ed. (8-1-12)

3 Occidental Fire & Casualty Company of North Carolina Applicant MUST answer all questions. Provide explanations in the Comments section below 1. Does anyone listed on this application reside outside of Colorado 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 compensation; to carry explosives or flammable items; 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 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 Colorado? X Y N (If No, list vehicle under "comments." Vehicle must be registered in Colorado within 30 days. 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. The agent recorded all of this information correctly. 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 this policy and any renewal shall be void from inception if I provided any information that is false, misleading or incomplete. I understand that the Company may reject this application, charge additional premiums, or cancel this policy if I have provided false, misleading or incomplete information. I understand that the Company may adjust the premium to agree with my motor vehicle record (MVR) and credit score. 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 MVR of anyone listed on this policy. I agree that the Company may charge the correct rate based upon the MVR. 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 a late fee will be charged if the Company does not receive my installment payment by the due date. 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, mode of living, and credit history 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 his wrong. I agree that my credit based insurance score is a factor used to determine my premium (unless I have opted out). I authorize the Company to review my credit report. I understand that a third party may be used to provide this information. I agree to be charged the following fees: $25 policy fee at inception and at every renewal; $35 fee for any dishonored payment; $25 [SR-22 filing fee if required]; $10 late payment fee; $10 reinstatement fee; $10 installment fee per payment or $5 per installment if EFT. 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. CO-OCC-APP Page 3 of 5 Ed. (8-1-12)

4 Occidental Fire & Casualty Company of North Carolina Applicant's Statement - Continued 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 PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. 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 / First 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 Medical Payments Coverage Colorado Statute requires that unless the named insured rejects this coverage in writing, every automobile liability policy delivered or issued in this state shall include coverage for medical payments with benefits of five thousand ($5000) dollars for bodily injury, sickness, or disease resulting from the ownership, maintenance or use of a motor vehicle (see policy jacket for specific terms and conditions). I hereby reject Medical Payments Coverage for this policy and renewal thereof. OR X I elect Medical Payments Coverage at a limit of $5000. X Signature of Applicant / First Named Insured Date CO-OCC-APP Page 4 of 5 Ed. (8-1-12)

5 Occidental Fire & Casualty Company of North Carolina Uninsured/Underinsured Motorist Coverage Uninsured/Underinsured Motorist Bodily Injury Coverage: Colorado statute requires that any company providing automobile liability insurance also provide Uninsured/Underinsured Motorist Bodily Injury (UMBI) coverage in an amount equal to the coverage limits of the policy's bodily injury liability coverage. This coverage protects the named insured, resident relatives of the named insured, and certain occupants of a covered vehicle for damages due to bodily injury or death that results from an accident caused by the owner or operator of an uninsured or underinsured motor vehicle (see policy jacket for specific terms and conditions). This coverage shall cover the difference, if any, between the amount of the limits of any legal liability coverage, and the amount of the damages sustained, excluding exemplary damages, up to the maximum amount of the coverage amount identified by a premium appearing in the declarations for UMBI. By making your selection below, you agree that your UMBI options have been fully explained and understood, and that you have the right to reject UMBI coverage in its entirety, or select a UMBI limit that is lower than your bodily injury liability limit. Initial next to your selection: X I do hereby reject Uninsured Motorist Bodily Injury Coverage entirely. OR I do hereby elect Uninsured Motorist Bodily Injury Coverage at the following limits: $25,000 per person/ $50,000 per accident $50,000 per person/ $100,000 per accident $100,000 per person/ $300,000 per accident (available on Elite Program only) Uninsured/Underinsured Motorist Property Damage (UMPD) Coverage (available only on vehicles that are not covered for collision): Colorado statute requires that at the request of the insured, coverage shall be provided for the protection of persons insured who are legally entitled to recover damages from the owner or operator of an uninsured motor vehicle because of property damage to the motor vehicle described in the policy arising out the ownership, operation or use of the uninsured motor vehicle. By making your selection below, you agree that your UMPD options have been fully explained and understood, and that you have the right to reject UMPD coverage in its entirety. X I hereby reject Uninsured Motorist Property Damage Coverage entirely. OR I hereby elect Uninsured Motorist Property Damage Coverage for: a. All vehicles listed on the policy with the following deductible: $100 $250 $500 $1000 b. The following vehicles only with the deductible indicated: 1. Year/Make/Model $100 $250 $500 $ Year/Make/Model $100 $250 $500 $ Year/Make/Model $100 $250 $500 $ Year/Make/Model $100 $250 $500 $ Year/Make/Model $100 $250 $500 $ Year/Make/Model $100 $250 $500 $1000 X Signature of Applicant / First Named Insured Date Coverage Selections And Limit Choices Acknowledgement I understand that the coverage selections and limit choices indicated above will apply to my policy and to all future renewals, continuations, reinstatements or changes unless I provide written notification to the Company in writing and pay all additional premiums due. I understand that it is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. If this policy includes Optional or Enhanced coverages (any coverage other than Liability, Medical Payments, and Uninsured/Underinsured motorist), the First Named Insured must indicate below that: The First Named Insured requested the Optional or Enhanced coverages; The Producer recommended the Optional or Enhanced coverages; or The First Named Insured requested some of the Optional or Enhanced coverages and the Producer recommended some of the Optional or Enhanced coverages. I the undersigned acknowledge that I am purchasing optional coverages. I understand that these coverages are not mandatory, and I hereby grant my consent to the addition of these coverages to the policy. X Signature of Applicant / First Named Insured Date CO-OCC-APP Page 5 of 5 Ed. (8-1-12)

6 Pre-Insurance Vehicle Inspection Report Agent Name: GONZALEZ INSURANCE Agent # Complete the information to identify the vehicle being inspected. Each vehicle requires a separate inspection form. 2. Check the appropriate boxes to indicate the accessories and optional equipment. 3. Put an X in the diagram of any part(s) damaged. Indicate the type of damage. 4. Comment of any customization/modification not included under #2 above. Note: If custom equipment is to be insured, please see manual for guidelines and rate: Date of Inspection Time Binder No. 01/05/15 OFCNC - OCCIDENTAL FIRE AND CASUALTY COMPANY OF NORTH CARO Insured Name Insured Address MANUELA I BONILLA 600 S DAYTON ST, B13 - AURORA, CO Description of Vehicle Color: Body Style: Year: 03 Make: NSSN ( ) 2 Door ( ) 4 Door ( ) P/U ( ) Van Vehicle Identification No: (obtain direct from Vehicle Dash or EPA Sticker) Taken From: JN8AZ08WX3W Odometer Reading: Plate No: State: Garage Zipcode: Accessories and Optional Equipment Items: ( ) Radio: ( ) AM/FM ( ) AM/FM Tape Deck ( ) Factory Installed X - Additional Items for Vans ( ) Interior Paneling Brand: ( ) Interior Rugs ( ) Stereo Amplifier Brand: ( ) Rear Passenger ( ) Compact Disk Player Brand: ( ) Exterior Decorative ( ) Factory Installed ( ) CB Radio ( ) Antenna ( ) Other than Factory Installed A/C Brand: ( ) Customized Windows or Bubbles ( ) Telephone ( ) Antenna ( ) Transmitter ( ) Beds Brand: ( ) Cots ( ) Anti-Theft Device Brand: ( ) Stereo Type: ( ) Radar Detector ( ) Air Conditioner ( ) Refrigerator ( ) Television ( ) Stove ( ) Manual Transmission: ( ) 3 Spd ( ) 4 Spd ( ) 5 Spd ( ) Automatic Other: ( ) Special Tires: Brand: ( ) Wheel Covers Standard: ( ) Custom Wheels: Brand: ( ) Special Roof: Brand: ( ) Other: ( ) No Damage 4. Right Front 5. Right Front Door 6. Right Rear Door 7. Right Rear 8. Rear 9. Left Rear Left Rear Door 11. Left Front Door 12. Left Front 13. Front 17. Hood 18. Roof/ Top 19. Trunk 20. Windshield 21. Windows 22. Underside 23. Overturn (Overall) Comments: The undersigned certifies that this Preinsurance Inspection Form is true and also attest to the authenticity of the Vehicle Identification Number X. X. Insured's Signature Date Agent's Signature Date

7 Pre-Insurance Vehicle Inspection Report Agent Name: GONZALEZ INSURANCE Agent # Complete the information to identify the vehicle being inspected. Each vehicle requires a separate inspection form. 2. Check the appropriate boxes to indicate the accessories and optional equipment. 3. Put an X in the diagram of any part(s) damaged. Indicate the type of damage. 4. Comment of any customization/modification not included under #2 above. Note: If custom equipment is to be insured, please see manual for guidelines and rate: Date of Inspection Time Binder No. 01/05/15 OFCNC - OCCIDENTAL FIRE AND CASUALTY COMPANY OF NORTH CARO Insured Name Insured Address MANUELA I BONILLA 600 S DAYTON ST, B13 - AURORA, CO Description of Vehicle Color: Body Style: Year: 02 Make: CHEV ( ) 2 Door ( ) 4 Door ( ) P/U ( ) Van Vehicle Identification No: (obtain direct from Vehicle Dash or EPA Sticker) Taken From: 2GCEC19V Odometer Reading: Plate No: State: Garage Zipcode: Accessories and Optional Equipment Items: ( ) Radio: ( ) AM/FM ( ) AM/FM Tape Deck ( ) Factory Installed X - Additional Items for Vans ( ) Interior Paneling Brand: ( ) Interior Rugs ( ) Stereo Amplifier Brand: ( ) Rear Passenger ( ) Compact Disk Player Brand: ( ) Exterior Decorative ( ) Factory Installed ( ) CB Radio ( ) Antenna ( ) Other than Factory Installed A/C Brand: ( ) Customized Windows or Bubbles ( ) Telephone ( ) Antenna ( ) Transmitter ( ) Beds Brand: ( ) Cots ( ) Anti-Theft Device Brand: ( ) Stereo Type: ( ) Radar Detector ( ) Air Conditioner ( ) Refrigerator ( ) Television ( ) Stove ( ) Manual Transmission: ( ) 3 Spd ( ) 4 Spd ( ) 5 Spd ( ) Automatic Other: ( ) Special Tires: Brand: ( ) Wheel Covers Standard: ( ) Custom Wheels: Brand: ( ) Special Roof: Brand: ( ) Other: ( ) No Damage 4. Right Front 5. Right Front Door 6. Right Rear Door 7. Right Rear 8. Rear 9. Left Rear Left Rear Door 11. Left Front Door 12. Left Front 13. Front 17. Hood 18. Roof/ Top 19. Trunk 20. Windshield 21. Windows 22. Underside 23. Overturn (Overall) Comments: The undersigned certifies that this Preinsurance Inspection Form is true and also attest to the authenticity of the Vehicle Identification Number X. X. Insured's Signature Date Agent's Signature Date

8 Pre-Insurance Vehicle Inspection Report Agent Name: GONZALEZ INSURANCE Agent # Complete the information to identify the vehicle being inspected. Each vehicle requires a separate inspection form. 2. Check the appropriate boxes to indicate the accessories and optional equipment. 3. Put an X in the diagram of any part(s) damaged. Indicate the type of damage. 4. Comment of any customization/modification not included under #2 above. Note: If custom equipment is to be insured, please see manual for guidelines and rate: Date of Inspection Time Binder No. 01/05/15 OFCNC - OCCIDENTAL FIRE AND CASUALTY COMPANY OF NORTH CARO Insured Name Insured Address MANUELA I BONILLA 600 S DAYTON ST, B13 - AURORA, CO Description of Vehicle Color: Body Style: Year: 12 Make: CHEV ( ) 2 Door ( ) 4 Door ( ) P/U ( ) Van Vehicle Identification No: (obtain direct from Vehicle Dash or EPA Sticker) Taken From: 1G1PK5SC4C Odometer Reading: Plate No: State: Garage Zipcode: Accessories and Optional Equipment Items: ( ) Radio: ( ) AM/FM ( ) AM/FM Tape Deck ( ) Factory Installed X - Additional Items for Vans ( ) Interior Paneling Brand: ( ) Interior Rugs ( ) Stereo Amplifier Brand: ( ) Rear Passenger ( ) Compact Disk Player Brand: ( ) Exterior Decorative ( ) Factory Installed ( ) CB Radio ( ) Antenna ( ) Other than Factory Installed A/C Brand: ( ) Customized Windows or Bubbles ( ) Telephone ( ) Antenna ( ) Transmitter ( ) Beds Brand: ( ) Cots ( ) Anti-Theft Device Brand: ( ) Stereo Type: ( ) Radar Detector ( ) Air Conditioner ( ) Refrigerator ( ) Television ( ) Stove ( ) Manual Transmission: ( ) 3 Spd ( ) 4 Spd ( ) 5 Spd ( ) Automatic Other: ( ) Special Tires: Brand: ( ) Wheel Covers Standard: ( ) Custom Wheels: Brand: ( ) Special Roof: Brand: ( ) Other: ( ) No Damage 4. Right Front 5. Right Front Door 6. Right Rear Door 7. Right Rear 8. Rear 9. Left Rear Left Rear Door 11. Left Front Door 12. Left Front 13. Front 17. Hood 18. Roof/ Top 19. Trunk 20. Windshield 21. Windows 22. Underside 23. Overturn (Overall) Comments: The undersigned certifies that this Preinsurance Inspection Form is true and also attest to the authenticity of the Vehicle Identification Number X. X. Insured's Signature Date Agent's Signature Date

9 COVERAGE PROVIDED BY: OCCIDENTAL FIRE AND CASUALTY COMPANY OF NORTH CAROLINA P.O. Box Raleigh, NC ADMINISTERED BY: National Insurance Underwriters: 800 Yamato Road #100, Boca Raton, FL PROCESS DATE 01/05/15 POLICY PERIOD DECLARATIONS POLICY NUMBER FROM: TO: OFCCO /05/15 07/05/15 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 cancel or refuse to renew your policy. INSURED AND ADDRESS PRODUCER # Phone: MANUELA I BONILLA 600 S DAYTON ST, B13 - AURORA, CO GONZALEZ INSURANCE 6450 E COLFAX AVE DENVER, CO COVERAGES LIMIT OF LIABILITY PREMIUM (IN DOLLARS) BODILY INJURY PROPERTY DAMAGE MEDICAL PAYMENTS UNINSURED MOTORIST-BI UNINSURED MOTORIST-PD OTHER THAN COLLISION COLLISION CUSTOM/SPECIAL EQUIPMENT SR22 FILING ROAD SERVICE ENDORSEMENT ANTI-THEFT FEE SNOW PLOW DED LIMITS $ $ $ $ $25, EACH PERSON $50, EACH ACCIDENT $25, EACH ACCIDENT $5, EACH PERSON EACH PERSON EACH ACCIDENT EACH ACCIDENT DED. EACH ACCIDENT CAR 1 CAR 2 CAR 3 ACTUAL CASH VALUE LESS DEDUCTIBLE ( ) Basic ( ) Deluxe ( X) Premier TOTAL TERM PREMIUM>>> $1, APPLIED DISCOUNT: 3YR Transfer MultiCar POLICY FEE>>> $25.00 EXCLUDED DRIVERS: See Attached CO-OCC-NDEE Ed. (9-1-09) POLICY TOTAL>>> $1, DESCRIPTION OF CARS CAR YEAR TRADE NAME MODEL BODY STYLE SYM/TYPE VEHICLE I.D. NUMBER TERR TYPE OF USE GARAGING ZIP NSSN CHEV CHEV MURANO SILVERADO CRUZE LOSS PAYEE / ADDITIONAL NAMED INSURED - NAME AND ADDRESS CAR # LP or AI NAME ADDRESS $ 500 $ 500 $ 500 $ 500 $ $ $ $ UTL4X44D PKP4X24D SEDAN 4D TOTAL CARS ON THIS PAGE>>> JN8AZ08WX3W GCEC19V G1PK5SC4C CAR 1 CAR 2 CAR 3 $62.00 $56.00 $71.00 $ $ $ $34.00 $35.00 $45.00 $61.00 $45.00 $76.00 $ $ $ $80.00 $1.50 Pleasure Pleasure Pleasure included included $ $ $ COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT ARE SHOWN FOR THE COVERAGE DRIVER INFORMATION DRIVER NAME D.O.B. POINTS STATE LICENSE NUMBER CLASS SR-22 Case # 1 2 MANUELA I BONILLA VICTOR M BECERRA 08/21/73 12/31/ CO CO MF41 MM40 ENDORSEMENTS APPLICABLE: Privacy Notice (CO-OCC-PRI ) COUNTERSIGNED BY CO-OCC-DEC Ed. (8-1-12) Authorized Representative INSURED COPY COUNTERSIGNED DATE Page 1 of 1

10 OCCIDENTAL FIRE & CASUALTY COMPANY OF NORTH CAROLINA COLORADO PRIVATE PASSENGER AUTOMOBILE INSURANCE SUMMARY DISCLOSURE FORM This summary disclosure form is a basic guide to the major coverages and exclusions in your policy. It is only a general description and not a statement of contract or a policy of any kind. All coverage is subject to the terms, conditions, and exclusions of your policy and all applicable endorsements. PLEASE READ YOUR POLICY FOR COMPLETE DETAILS! THIS SUMMARY DISCLOSURE FORM SHALL NOT BE CONSTRUED TO REPLACE ANY PROVISION OF THE POLICY ITSELF. Complete details includes, but is not limited to, information on the method your insurer uses to calculate your unearned premium (e.g., pro rata or short rate), if you should cancel your policy mid-term or before the next renewal. This summa ry disclosure form also provides the factors considered for cancellation, nonrenewal and increase-in-premium. These factors are general in nature and do not represent the only reasons a policy may be terminated or changed. Please contact your agent or insurer for further information. See the information on the attached pages. I. REQUIRED COVERAGES Colorado law requires you to carry liability coverage on your automobile. Liability coverage pays for bodily injury to another person and for property damage to another s property caused by the negligent (at- fault) operation of your automobile up to the limits of your policy. EXCLUSIONS - LIABILITY COVERAGE - Coverage is not provided for any automobile owned by you or a resident relative that is not insured for liability under your policy. There is no coverage for intentional acts. Other exclusions are listed in your policy. II. OTHER COVERAGES A. Uninsured and Underinsured Motorist Coverage You must be offered uninsured and underinsured motorist coverage, and it will be included in your policy unless you reject it in writing. Uninsured Motorist coverage pays for bodily injury that you are entitled to collect from a hit-and-run or uninsured driver who is at fault for the accident. Underinsured Motorist coverage pays for bodily injury that you are entitled to collect from an underinsured owner or driver who is at fault for the accident and when the damages exceed the driver s liability coverage. Generally, an underinsured automobile is an automobile whose liability coverage is not enough to pay the full amount you are legally entitled to recover as damages. CO Summary Disclosure Page 1 of 4 Ed. (9-1-09) {CO Ed }

11 Coverage may be available under multiple policies in certain circumstances. For example, a passenger in a vehicle that is not at fault in the accident may have uninsured or underinsured coverage under the policy covering the vehicle and the passenger s own policy on their vehicle(s) not involved in the accident. This adding of limits under two or more policies is commonly referred to as stacking. Please consult your agent or insurer if y ou have any questions or for further details. EXCLUSIONS - UNINSURED AND UNDERINSURED MOTORIST COVERAGE. Coverage is not provided for any insured who, without the written consent of the insurer, settles with any person or organization who may be liable for the bodily injury. Other exclusions may be listed in the policy. B. Physical Damage Coverages Collision and Comprehensive You must be offered collision coverage. Collision coverage pays for damage to your own automobile. It provides coverage when your automobile collides with another automobile or object, or if your automobile overturns. Comprehensive (referred to throughout the policy and hereafter as "Other Than Collision") coverage pays for damage to your automobile from causes such as fire, theft, vandalism, hail, and falling objects. Collision and Other Than Collision coverage may be written with a deductible. A deductible is that part of a loss for which you, the insured, are responsible. Your insurer will pay for the balance of covered repairs subject to your policy provisions. A lender may require you to purchase both Collision and Other Than Collision coverage. EXCLUSIONS - COLLISION AND OTHER THAN COLLISION. Coverage does not apply to losses that occur while your automobile is rented or leased to others. There is no coverage for wear, tear, freezing, mechanical failure or breakdown, or road damage to tires. Additional restrictions may apply to special equipment. Other exclusions are listed in your policy. C. Medical Payments Coverage Your policy provides medical payments coverage of $5,000 unless you reject it in writing, or in the same medium in which you completed the application for the policy. Medical payments coverage pays for reasonable health care expenses incurred for bodily injury caused by an automobile accident, regardless of fault, up to the policy limits chosen by the insured. Your insurer must prioritize payment of the medical payments coverage benefits in a manner consistent with SS (2)(b), C.R.S. Medical payments coverage is primary to any health insurance coverage available to an insured when injured in an automobile accident. Medical payments coverage applies to any coinsurance or deductible amount required to be paid by the person's health coverage plan as defined in SS (22.5), C.R.S. CO Summary Disclosure Page 2 of 4 Ed. (9-1-09) {CO Ed }

12 An insured that is injured in an automobile accident will not receive benefits from medical payments coverage for any medical expenses incurred as a result of an accident that is the fault of the insured unless medical payments coverage is purchased. Read your policy to see who is a covered person under medical payments coverage. D. Uninsured Motorist Property Damage This is an optional coverage you can request if you do not have collision coverage on your vehicle. 1. Uninsured Motorist Property Damage (UMPD) pays for damages to your vehicle caused by an at-fault owner of an uninsured motor vehicle. 2. UMPD will not pay if the vehicles do not physically make contact. 3. UMPD only covers actual cash value of your vehicle or cost of repair or replacement, which ever is less. III. CANCELLATION, NONRENEWAL AND INCREASE IN PREMIUM A. Cancellation During the first 59 days your company may cancel your policy for any reason that is not unfairly discriminatory or prohibited by law. After your policy has been in effect for more than 59 days, your company may cancel your policy for any of the following reasons: 1. Failure to pay your premium when it is due; 2. Knowingly making a false statement on your application for an automobile policy; 3. A driver s license suspension or revocation during the policy period for you, a member of your household, or any ot her driver who regularly uses your automobile. B. Nonrenewal Your company may choose to non-renew your policy. Some examples of reasons for nonrenewal include, but are not limited to: 1. An unacceptable number of traffic convictions; 2. An unacceptable number of negligent (at-fault) accidents; 3. Conviction of a major violation such as drunk driving or reckless driving. CO Summary Disclosure Ed. (9-1-09) {CO Ed } Page 3 of 4

13 C. Increase in Premium The following factors may increase your premium: a premium surcharge may be added or an accident free discount removed as a result of an at-fault accident or traffic conviction. The following conditions may increase your premium: 1. Change of garage location of the automobile; 2. Change of automobile(s) insured; 3. Addition of driver; 4. Change in use of your automobile; 5. A general rate increase. This results from the loss experience of a large group of policyholders rather than from a loss suffered by an individual policyholder. A general rate increase applies to everyone in the group, not just those who had losses. The above list of factors and conditions is not all inclusive and there may be other factors or conditions that increase your premium. CO Summary Disclosure Page 4 of 4 Ed. (9-1-09) {CO Ed }

14 Notice of Privacy Policy Occidental Fire & Casualty Company of North Carolina Occidental values you as a customer and respects your right to privacy. We respect your right to keep your personal information confidential and to avoid unwanted solicitations. Occidental has established the policies outlined below with regard to the handling of your nonpublic personal information. Nonpublic personal information is information we obtain about you that is not available to the general public, which we obtain in connection with providing a financial product or service to you. Information We May Collect We collect information we believe is necessary to administer our business, to advise you about our products and services, and to provide you with customer service. Most of the information that we collect is taken directly from the application for insurance that you completed when you contacted your agent such as name, address, telephone number, driver's license number, social security number, etc. We also gather information from your transactions with us, such as your payment history, underwriting and claim documents. We may also gather information from non - Occidental companies such as your driving records and claim history. Information Disclosure In order to better serve you and assist in meeting your product and service needs, we share our in formation about your auto insurance transactions and experiences with companies related to us by common control or ownership and with Occidental agents. We may also disclose customer information about you to persons or organizations inside or outside our group of companies as permitted by law, including other financial institutions and companies that perform marketing services for us or with whom we have joint marketing agreements. We may also share customer information as necessary to handle your claim and to protect you against fraud and unauthorized transactions. It is our policy not to disclose any nonpublic personal information about you to any third parties that are not permitted by law. Security of Information We also take steps to safeguard customer information. We maintain physical, electronic and organizational safeguards to protect your nonpublic personal information. We restrict access to your information to those employees and other parties who need to know that information to provide products or services to you. P.O. Box 10800, Raleigh, NC CO - OCC - PRI ( )

15 Occidental Fire & Casualty Company of North Carolina Colorado Rental Reimbursement and Road Service Endorsement THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This coverage is additional insurance. No deductible applies to this coverage. Please refer to the Declarations or to your ID card to determine the level of benefit purchased. COVERAGES BASIC BENEFIT LIMITS PLAN LETTER B DELUXE BENEFIT LIMITS PLAN LETTER C PREMIER BENEFIT LIMITS PLAN LETTER D Dispatch Towing Benefit Maximum 15 Miles per Tow Maximum 25 Miles per Tow Maximum 35 Miles per Tow Rental Reimbursement $20 per day up to $200 Annual Aggregate $20 per day up to $300 Annual Aggregate $20 per day up to $400 Annual Aggregate Dispatch Roadside Assistance/Lockout COVERED COVERED COVERED Personal Effects in rental car Up to Limit of $200 per occurrence Up to Limit of $300 per occurrence Up to Limit of $400 per occurrence Theft Hit & Run Reward $500 $750 $1000 Premium (Semi-Annual) $35.00 $55.00 $80.00 Annual Premium is twice the Semi-Annual Premium COVERAGES: (a) Towing and Road Service 24-Hour Toll-Free Emergency Dispatch Service Procedures Definitions: For purposes of this endorsement, collision means the upset of your covered auto or its impact with another vehicle or object (excluding animals). Your covered auto means the auto(s) shown in the declarations, any additional auto, or any replacement auto. Your benefit limit means the benefit limit shown in the table above for the program indicated in the declarations. If your covered auto becomes disabled and you need help, call the Emergency Dispatch Center 24-Hours a day, 365 days a year at When they answer, give the operator: 1. Your name, Producer Code 91876, and the plan letter indicated on your Declarations, or on your ID card. 2.The area code and number of the telephone from which you are calling. 3.The location of the disabled vehicle (town, state, zip code, street address, closest intersection) 4.A description of the vehicle (year, make, model, color) and your vehicle's license plate number. 5.The type of problem you are having. The dispatch operator will notify a service provider and provide you with an estimated time when help will arrive. Service provider will be paid directly for towing or service charges up to your benefit limit; or, if you pay for covered services, you will be reimbursed up to a maximum of $50 per occurrence, provided you submit all receipts. When the service provider arrives: 1.Service will be provided only if you are with your vehicle, unless other arrangements were made in advance with the dispatch operator. You are responsible for staying in a safe place until the service provider arrives. 2.Show your I.D. card to the service provider. 3.Sign the service provider's receipt for covered expenses up to your benefit limit. CO-OCC-RSE Page 1 of 3 Ed. (9-1-09)

16 You are responsible for the payment of any additional expenses not covered beyond your benefit limit. Please see the Exclusions section for expenses not covered. This coverage will be provided on a per occurrence basis, for towing and road service costs incurred each time your covered auto is disabled. You will only be covered for the labor performed at the place of disablement. There is no limit on the number of claims per year. There is a limit of one tow or road service per incident. Exclusions: There is no coverage for: 1.Events that did not take place on a public roadway or services required in areas not regularly traveled (e.g. sand beaches, open fields, forests and areas designated as not passable due to construction, an act of nature, etc.). 2.Events where the insured person was cited for any of the following: a.dui/dwi; b.using the vehicle in the commission of a crime; c.leaving the scene of an accident; or d.hit and run. 3.Maintenance Services. 4.Parts, products, storage or gasoline. 5.Services provided by private parties or unlicensed facilities. 6.Towing: a.out of a place of Repair; or b.out of impound areas, except for accident or theft recovery. 7.Any other expenses not specifically mentioned as covered. (b) Rental Reimbursement-this coverage is limited to an annual aggregate payment not to exceed your benefit limit. If your covered auto is disabled due to collision, you will be reimbursed up to $20 per day up to your benefit limit, for expenses you incur for a rental vehicle. This coverage begins 24 hours after your covered auto is disabled and ceases: 1)Upon completion of repairs to your covered auto; or 2)Upon exhaustion of your benefit limit; whichever comes first. You must obtain a police report at the scene of the accident or within a reasonable time thereafter, but no later than 10 days from the day of the accident unless physically unable to do so. A bill from an automobile repair shop stating the nature of the repairs along with the dates of entry and release of the automobile must be submitted. In addition, you must submit proof of expenditure from a bona fide car rental agency. You must also submit any other documents that we reasonably request. Exclusions: We will not cover: 1.Events where the insured was cited for any of the following: a.dui/dwi; b.using the vehicle in the commission of a crime; c.leaving the scene of an accident; or d.hit and run. 2.Maintenance Services. 3.Expenses incurred for rental of vehicles from private parties or unlicensed facilities. 4.Excessive rental expenses due to unreasonable repair delays. 5.Any loss to any vehicle used in any way for business. 6.Any other expenses not specifically mentioned as covered. (c) Lockout Coverage Service will be dispatched to assist you if your covered auto's keys are accidentally locked inside your covered auto (passenger compartment only). There is no coverage for the cost of replacement keys or for costs for the repair of mechanical failure of your covered auto's locks or ignition system. CO-OCC-RSE Page 2 of 3 Ed. (9-1-09)

17 (d) Personal Effects (in Rental Car)-This coverage is limited to an annual aggregate payment not to exceed your benefit limit. In the event of theft of personal property owned by you or any family members while such property is located within the passenger compartment or storage compartments of a rental car, you will be paid the actual cash value (replacement cost less depreciation) of said property up to a maximum of your benefit limit. This coverage applies only in the event that you rent a car from a licensed rental car company, and that the car is rented for your personal use. No coverage applies unless a police report is filed within 24 hours of the date you discover the theft. (e) Additional Benefit Theft, Hit & Run Reward Your benefit limit will be paid as a reward to the witness or witnesses who provide information leading to the arrest and conviction of anyone stealing your covered auto or responsible for causing bodily injury to you or your family members, as a result of a hit-and-run. No deductible applies to this benefit. To obtain reimbursement, you must mail a request for reimbursement to us within 90 days of conviction. You must include: 1.A copy of all documents pertaining to the incident, including the arresting officer's name, badge number and address, as well as the current address of the witness and the relationship, if any, of the witness to you; and 2.A copy of the final court transcript or the conviction report showing the exact offense(s) of which the thief or hit-and-run driver was finally convicted and containing a reference to the fact that the person claiming the reward provided information leading to that conviction. This benefit will not be paid to: You or any family member; Law enforcement officials and/or members of their families, or anyone accompanying you or your family member(s) at the time and location of the theft or accident. All other provisions of this policy apply. CO-OCC-RSE Page 3 of 3 Ed. (9-1-09)

18 Occidental Fire and Casualty Company of North Carolina Claim Telephone # Colorado Policy Identification Card Policy Number Effective Date Expiration Date OFCCO /05/15 07/05/15 Year/Make/Model Vehicle Identification Number 03 NSSN MURANO JN8AZ08WX3W Insured: MANUELA I BONILLA 600 S DAYTON ST, B13 - AURORA, CO (X) Bodily Injury / Property ( ) UM BI ( ) UM PD Damage Liability (X) Medical Payments (X) Full Coverage Not valid more than one year from inception. ROAD SERVICE PROCEDURE If Your covered auto becomes disabled and you need help, call the Emergency Dispatch Center 24-Hours a day, 365 days a year at When they answer, give the operator: 1. Producer Code Plan Letter D WHAT TO DO AT TIME OF ACCIDENT DO NOT admit fault. Make no statement regarding the accident to anyone other than our claims representatives DO NOT reveal the armount of your policy limits to anyone. Obtain names, addresses, phone numbers and insurance information from the other drivers. Obtain names, addresses and phone numbers for any other vehicle occupants or witnesses. Report all accidents promptly to our Claims Road Service Endorsement: Agent #91876; Plan #D20; Membership # D20 Call the Toll Free Claims Hotline Numbers: Towing & Roadside Assistance Rental Reimbursement Accident Information Form KEEP THIS INFORMATION IN YOUR VEHICLE. PLEASE COMPLETE ALL DETAILS IN CASE OF AN ACCIDENT AND CONTACT OUR CLAIMS OFFICE IMMEDIATELY. Dear Insured: It is critical you immediately report any claim directly to our claims office, whether or not you are at fault. Our service representatives will instruct you at that time on the proper procedures to follow. Claims, and the efficient handling of them, are of great importance to you and is a service in which we take pride. Should an accident occur, our claims office can be reached toll free at: Details of Accident Date & Time of Accident: Location: Street & City: Were Police Notified: ( )No ( )Yes: Police Dept: Case # Citations Issued by Police Injuries: ( )No ( )Yes: Type: Person Injured: Vehicle Driveable? ( )Yes ( )No: Vehicle removed to: Other Car Insurance Company Name: Policy Number: Owner of Car: Phone # Make & Model of Car: Tag# Injuries: ( )No ( )Yes: Type: Person Injured: Witness Information Name: Address: NATIONAL ADJUSTMENT BUREAU 800 Yamato Road #100, Boca Raton, FL Name: Address: Phone #: Phone #: CO-OCC-ID

19 Occidental Fire and Casualty Company of North Carolina Claim Telephone # Colorado Policy Identification Card Policy Number Effective Date Expiration Date OFCCO /05/15 07/05/15 Year/Make/Model Vehicle Identification Number 02 CHEV SILVERADO 2GCEC19V Insured: MANUELA I BONILLA 600 S DAYTON ST, B13 - AURORA, CO (X) Bodily Injury / Property ( ) UM BI ( ) UM PD Damage Liability (X) Medical Payments (X) Full Coverage Not valid more than one year from inception. ROAD SERVICE PROCEDURE If Your covered auto becomes disabled and you need help, call the Emergency Dispatch Center 24-Hours a day, 365 days a year at When they answer, give the operator: 1. Producer Code Plan Letter D WHAT TO DO AT TIME OF ACCIDENT DO NOT admit fault. Make no statement regarding the accident to anyone other than our claims representatives DO NOT reveal the armount of your policy limits to anyone. Obtain names, addresses, phone numbers and insurance information from the other drivers. Obtain names, addresses and phone numbers for any other vehicle occupants or witnesses. Report all accidents promptly to our Claims Road Service Endorsement: Agent #91876; Plan #D20; Membership # D20 Call the Toll Free Claims Hotline Numbers: Towing & Roadside Assistance Rental Reimbursement Accident Information Form KEEP THIS INFORMATION IN YOUR VEHICLE. PLEASE COMPLETE ALL DETAILS IN CASE OF AN ACCIDENT AND CONTACT OUR CLAIMS OFFICE IMMEDIATELY. Dear Insured: It is critical you immediately report any claim directly to our claims office, whether or not you are at fault. Our service representatives will instruct you at that time on the proper procedures to follow. Claims, and the efficient handling of them, are of great importance to you and is a service in which we take pride. Should an accident occur, our claims office can be reached toll free at: Details of Accident Date & Time of Accident: Location: Street & City: Were Police Notified: ( )No ( )Yes: Police Dept: Case # Citations Issued by Police Injuries: ( )No ( )Yes: Type: Person Injured: Vehicle Driveable? ( )Yes ( )No: Vehicle removed to: Other Car Insurance Company Name: Policy Number: Owner of Car: Phone # Make & Model of Car: Tag# Injuries: ( )No ( )Yes: Type: Person Injured: Witness Information Name: Address: NATIONAL ADJUSTMENT BUREAU 800 Yamato Road #100, Boca Raton, FL Name: Address: Phone #: Phone #: CO-OCC-ID

20 Occidental Fire and Casualty Company of North Carolina Claim Telephone # Colorado Policy Identification Card Policy Number Effective Date Expiration Date OFCCO /05/15 07/05/15 Year/Make/Model Vehicle Identification Number 12 CHEV CRUZE 1G1PK5SC4C Insured: MANUELA I BONILLA 600 S DAYTON ST, B13 - AURORA, CO (X) Bodily Injury / Property ( ) UM BI ( ) UM PD Damage Liability (X) Medical Payments (X) Full Coverage Not valid more than one year from inception. ROAD SERVICE PROCEDURE If Your covered auto becomes disabled and you need help, call the Emergency Dispatch Center 24-Hours a day, 365 days a year at When they answer, give the operator: 1. Producer Code Plan Letter D WHAT TO DO AT TIME OF ACCIDENT DO NOT admit fault. Make no statement regarding the accident to anyone other than our claims representatives DO NOT reveal the armount of your policy limits to anyone. Obtain names, addresses, phone numbers and insurance information from the other drivers. Obtain names, addresses and phone numbers for any other vehicle occupants or witnesses. Report all accidents promptly to our Claims Road Service Endorsement: Agent #91876; Plan #D20; Membership # D20 Call the Toll Free Claims Hotline Numbers: Towing & Roadside Assistance Rental Reimbursement Accident Information Form KEEP THIS INFORMATION IN YOUR VEHICLE. PLEASE COMPLETE ALL DETAILS IN CASE OF AN ACCIDENT AND CONTACT OUR CLAIMS OFFICE IMMEDIATELY. Dear Insured: It is critical you immediately report any claim directly to our claims office, whether or not you are at fault. Our service representatives will instruct you at that time on the proper procedures to follow. Claims, and the efficient handling of them, are of great importance to you and is a service in which we take pride. Should an accident occur, our claims office can be reached toll free at: Details of Accident Date & Time of Accident: Location: Street & City: Were Police Notified: ( )No ( )Yes: Police Dept: Case # Citations Issued by Police Injuries: ( )No ( )Yes: Type: Person Injured: Vehicle Driveable? ( )Yes ( )No: Vehicle removed to: Other Car Insurance Company Name: Policy Number: Owner of Car: Phone # Make & Model of Car: Tag# Injuries: ( )No ( )Yes: Type: Person Injured: Witness Information Name: Address: NATIONAL ADJUSTMENT BUREAU 800 Yamato Road #100, Boca Raton, FL Name: Address: Phone #: Phone #: CO-OCC-ID