NEW AUTOMOBILE POLICY DECLARATIONS ADMINISTERED BY: Multi-State Insurance Services, Inc P.O. BOX 801208 SANTA CLARITA CA 91380-1208 MGA LICENSE #1557695 THIS DECLARATION PAGE IS PART OF YOUR POLICY. PLEASE READ IT CAREFULLY. NAMED INSURED: PRODUCER: 7664 Phone Number: A E A AGENCY INC DBA: AMTEX AUTO 5909 WEST LOOP S #525 BELLAIRE, TX 77401-0000 POLICY NUMBER: HSP0099648 01/20/2017 to 07/20/2017 POLICY TERM: 01/20/2017 to 07/20/2017 at 12:01 A.M. COVERAGES AND PREMIUMS Coverage is provided only if a premium is shown for the indicated coverage. COVERAGES LIMITS OF LIABILITY VEH 1 VEH 2 VEH VEH VEH VEH Bodily Injury Liability $30,000 per person $60,000 per accident $212 $125 Property Damage Liability $25,000 per accident $168 $116 Medical Payments Personal Injury Protection per person, per accident per person, per accident UM / UIM Bodily Injury per person per accident UM / UIM Property Damage $250 Deductible Applies per accident Comprehensive 1 2 Collision 1 2 Rental Reimbursement Towing and Labor Costs PER VEHICLE TOTALS $380 $241 ACCIDENTAL DEATH AND DISMEMBERMENT PER ACCIDENT Coverage for ONLY 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. Total Vehicle Premium $621.00 Policy Fee $66.00 Automobile Burglary and Theft Prevention Authority Fee $2.00 (See enclosed explanation) SR22 Filing Fee(s) $0.00 Total Premium and Fees* $689.00 *An Installment Fee of $5 will be charged for every installment, except the down-payment, and will not be charged if installments are not used. This fee is not included in the Total Premium and Fees. FORMS AND ENDORSEMENTS WHICH APPLY BUSEXCL 12/2010, TX-UMREJECT 10/2012, TX-HSCMIC-LIMDISC 09/2013, TX-MSIS-HSCMIC-LTDPAP 09/2013, TX-MSIS-HSCMIC-APP 02/2016 TX-MSIS-HSCMIC-DEC (02/16) Page 1 of 2 Date Printed: 04/22/2018 Insured Copy
HSP0099648 Policy Number: HSP0099648 VEHICLE DESCRIPTION Coverage is provided only for the vehicles listed below and only if at the listed garaging address. # Year Make Model VIN Discounts / Garaging Rated Sym Terr Vehicle Use Surcharges Zip Code Driver 1 2007 FORD EXPEDITION 1FMFU15527LA51240 MC 11/ 11 59 79761 Pleasure 1 XLT/EXPEDITI ON SSV 2 2004 FORD F-350 SUPER 1FTSW31P84EC36778 MC 18/ 18 59 79761 Pleasure 2 DUTY SRW CREW CAB Discount Codes: PER = Persistency / MC = Multi-Car / SD = Safe Driver / RD = Renewal Discount Surcharge Codes: BU = Business Use / CV = Customized Van / HRV = High Risk Vehicle / PRVE = Prohibited Vehicle / RTC = Recent Title Change / BT = Branded Title / SPI = Severe Problem Indicator LIENHOLDERS / ADDITIONAL INSUREDS # Type Name Address COVERED DRIVER(S) # Name DOB Age License State Gender Marital Status Points Surcharges 1 03/31/1965 51 10423484 TX Male Single 8 2 JUAN ANTONIO GARCIA- CAZARES 06/17/1970 46 00628698 TX Male Single 0 Surcharge Codes: DR = 3-year Driving Record / FORL = Foreign License / SL = Suspended License / ID = ID Card ONLY / UNOP= Unacceptable Operator / UMVR = Unverifiable Motor Vehicle Record EXCLUDED DRIVER(S): This policy shall not apply nor accrue to the benefit of any insured or any third party when any vehicle is being used or driven by a person listed below. TX-MSIS-HSCMIC-DEC (02/16) Page 2 of 2 Date Printed: 04/22/2018 Insured Copy
Name and Address of Insured Nombre y Dirección del Asegurado Insured Drivers: Conductores Asegurados: Insurance Company Agent A E A AGENCY INC DBA: AMTEX AUTO Policy Number Effective Date Expiration Date Compañía de Seguro Agente A E A AGENCY INC DBA: AMTEX AUTO Número de Póliza Fecha Efectiva Fecha de Expiración HSP0099648 01/20/2017 07/20/2017 HSP0099648 01/20/2017 07/20/2017 Vehicle 2007 FORD EXPEDITION XLT/EXPEDITION SSV VIN: 1FMFU15527LA51240 Vehículo 2007 FORD EXPEDITION XLT/EXPEDITION SSV VIN: 1FMFU15527LA51240 This policy provides at least the minimum amounts of liability insurance required by the Texas Motor Vehicle Safety Responsibility Act for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. Texas Liability Insurance Card Keep this card. IMPORTANT: This card or a copy of your insurance policy must be shown when you apply for or renew your: Motor vehicle registration Driver s license Motor vehicle safety inspection sticker. Esta póliza prove por lo menos la cantidad minima de seguro de responsabilidad requerida por ley (Texas Motor Vehicle Safety Responsibility Act) para el vehículo especificado y para los asegurados nombrados, y puede proveer cobertura para otras personas y otros vehículos según provisto en la póliza de seguro. Tarjeta de Seguro de Responsabilidad de Texas Departamento de Seguros Guarde esta tarjeta. IMPORTANTE: Esta tarjeta o una copia de su póliza de segure debe ser mostrada cuando usted solicite o renueve su: Registro de vehículo de motor Licencia para conducir Etiqueta de inspección de segurida para su vehículo 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. Failure to do so could result in fines up to $1,000, suspension of your driver s license and motor vehicle registration, and impoundment of your vehicle for up to 180 days (at a cost of $15 per day). Puede que usted tenga que mostrar esta tarjeta o su póliza si usted tiene un accidente o si un official de paz se la pide. Todos los conductors en Texas deben tener seguro de responsabilidad para sus vehículos, o de otra manera llena los requisites legales de responsabilidad civil. Fallo en llener este requisite pudiera resultar en multas de hasto $1,000, suspension de su licencia para conducer y su registro de vehículo de motor y la retención de su vehículo por un period de hasta 180 días (a un costo de $15 por día). TX-IDCARD (01/11)
Name and Address of Insured Nombre y Dirección del Asegurado Insured Drivers: Conductores Asegurados: Insurance Company Agent A E A AGENCY INC DBA: AMTEX AUTO Policy Number Effective Date Expiration Date Compañía de Seguro Agente A E A AGENCY INC DBA: AMTEX AUTO Número de Póliza Fecha Efectiva Fecha de Expiración HSP0099648 01/20/2017 07/20/2017 HSP0099648 01/20/2017 07/20/2017 Vehicle 2004 FORD F-350 SUPER DUTY SRW CREW CAB VIN: 1FTSW31P84EC36778 Vehículo 2004 FORD F-350 SUPER DUTY SRW CREW CAB VIN: 1FTSW31P84EC36778 This policy provides at least the minimum amounts of liability insurance required by the Texas Motor Vehicle Safety Responsibility Act for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. Texas Liability Insurance Card Keep this card. IMPORTANT: This card or a copy of your insurance policy must be shown when you apply for or renew your: Motor vehicle registration Driver s license Motor vehicle safety inspection sticker. Esta póliza prove por lo menos la cantidad minima de seguro de responsabilidad requerida por ley (Texas Motor Vehicle Safety Responsibility Act) para el vehículo especificado y para los asegurados nombrados, y puede proveer cobertura para otras personas y otros vehículos según provisto en la póliza de seguro. Tarjeta de Seguro de Responsabilidad de Texas Departamento de Seguros Guarde esta tarjeta. IMPORTANTE: Esta tarjeta o una copia de su póliza de segure debe ser mostrada cuando usted solicite o renueve su: Registro de vehículo de motor Licencia para conducir Etiqueta de inspección de segurida para su vehículo 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. Failure to do so could result in fines up to $1,000, suspension of your driver s license and motor vehicle registration, and impoundment of your vehicle for up to 180 days (at a cost of $15 per day). Puede que usted tenga que mostrar esta tarjeta o su póliza si usted tiene un accidente o si un official de paz se la pide. Todos los conductors en Texas deben tener seguro de responsabilidad para sus vehículos, o de otra manera llena los requisites legales de responsabilidad civil. Fallo en llener este requisite pudiera resultar en multas de hasto $1,000, suspension de su licencia para conducer y su registro de vehículo de motor y la retención de su vehículo por un period de hasta 180 días (a un costo de $15 por día). TX-IDCARD (01/11)
Important Notice About Our Information Practices And The Protection Of Your Privacy Multi-State Insurance Services, Inc. - CA License #0D08447, FL License #W137320, TX License #1557695, WA License #794312 Multi-State General Agency, Inc. TX License #1695738 The Company authorization shall be valid for 12 months We value your business and trust you ve placed with us. That s why we want to assure you that we are serious about keeping your personal information private before, during and after your business relationship with us. This notice describes our policy regarding the collection, disclosure and protection of your non-public personal information. Information We Collect. We obtain most of our information directly from you. Depending on the nature of your insurance transaction, we may also collect information about you or other individuals proposed for insurance from other sources. The type and source of information we collect about you or other persons proposed for insurance is as follows: Information the insurance agent receives from you as part of your application for insurance or contained in other insurance forms, such as your name, address, and telephone number; and Claims, billing, payment history, and other transaction information we receive from you, our affiliates and others; and Information we receive from other agents, brokers, administrators, investigators, insurance support agencies, legal counsel, consumer reporting agencies and government reporting agencies. The information received from these sources may include inspections and investigative reports, audits, consumer reports, driving records, asset information, insurance underwriting records, records relating to prior insurance, and legal opinions. Unless it is specifically stated otherwise in an amended Privacy Policy Notice, no additional information will be collected about you. Information We May Disclose To Affiliates And Third Parties. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law. We may disclose some or all of the nonpublic personal information described above that we collect about you to the following affiliates and nonaffiliated third parties to effect, administer, or enforce your insurance transaction: Claims administrators; Insurance agents or brokers; Appraisers, Inspectors, and other insurance support services; Consumer reporting agencies; Governmental agencies when required to do so; An affiliate or third party for the purpose of conducting an audit of the insurance institution or agent in connection with the operations or services provided; To a lien holder, mortgagee, assignee, or other person having a legal or beneficial interest in the policy of insurance; and To persons or agencies lawfully entitled to such information pursuant to a facially valid subpoena or court order. Information obtained from a report prepared by an insurance support organization may be retained by the insurance support organization and disclosed to other persons. Personal information and other privileged information collected by us or your agent may in certain circumstances be disclosed to third parties without your authorization, as permitted or required by law. Our Practices Regarding Use of your Personal Information for Marketing Purposes. We do not share your financial information with our affiliates to market products or services to you. We do not sell your personal information to anyone. Nor do we share it with entities or organizations outside of our company that would use that information to contact you about their own products and services. Should our practice ever change, we will offer you the ability to prohibit this type of information sharing and would offer you the opportunity to opt-out of this type of information sharing, and we would offer you the opt-out with time for you to respond before the change in our practice takes place. Our Practices Regarding Information Confidentiality And Security. We restrict access to nonpublic personal information about you to those individuals who need to know that information to provide products or services to you. We also maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. A more detailed description of our information practices and your right to privacy is available to you by submitting a request in writing to us at the address indicated below. Access to and Correction of Your Information. You may write to us at if you have any questions about the information that we may have in our records about you. If you wish, you may inspect this information in person or receive a copy at a reasonable charge by sending us a written request. You can notify us in writing if you believe any information should be corrected, amended, or deleted and we will review your request. We will either make the requested change or explain why we did not do so. If we do not make the requested change, you may submit a short written statement identifying the disputed information, which will be included in all future disclosures of your information. You may send your written request to us at: Multi-State Insurance, P.O. Box 801208, Santa Clarita CA 91380-1208 Attn: Operations. All written requests must include your name, address, telephone number, policy number, and a photocopy of a picture ID for identification purposes. MSI-PRVNOT (04/13)