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National General >, <br />Auto, Home & Health Insurance <br />PO Box 3199 • Winston Salem, NC 27102-3199 <br />THOMAS E BYSTRY <br />14 APPOMATTOX <br />IRVINE CA 92620 <br />Policy Number: 2006521219 <br />Named Insured: <br />Thomas E Bystry <br />Policy Period: 12:01 A.M. <br />5/21/2019 - 5/21/2020 <br />Date of Notice: 5/7/2019 <br />Policy Underwritten By: <br />Integon National <br />Insurance Company <br />24 Hour Claim Reporting: 1-800.468.3466 <br />For Policy Information: 1-877468-3466 <br />www.MyNatGenPolicy.com <br />Your Agent: <br />Fiesta Auto Insurance Center Store <br />#Ca078 <br />1714 E McFadden Ave Ste P <br />Santa Ana CA 92705 <br />(714)884-4284 <br />CA COMMERCIAL VEHICLE DECLARATIONS PAGE <br />Endorsement Effective 5/2112019 <br />The following changes were made to your policy - Policy Level Change <br />Drivers, Employees and Household Residents <br />#1 Thomas E Bystry <br />Driver Status License # Lic State <br />Date of Birth <br />Gender <br />Marital Status <br />Driver Pts <br />Yrs. Licensed <br />Owner Driver XXX9358 CA <br />10/26/1957 <br />Male <br />Married <br />0 <br />45 <br />#2 Jennifer L Bystry <br />Driver Status License # Lic State <br />Date of Birth <br />Gender <br />Marital Status <br />Driver Pts <br />Yrs. Licensed <br />Relative <br />2/6/1978 <br />Female <br />Married <br />0 <br />25 <br />Excluded <br />Insured Vehicle(s) and Schedule of Coverages <br />#1 2011 HOND ELEMENT LX <br />VIN: Usage: Personal Use Radius: 0 <br />5J6YH1H32131-003266- Only <br />BD3335 <br />Garaging Location: <br />92620 <br />Policy Coverage Lev _ el. ____— -------ScheduledAuto <br />-Coverages Provided <br />Limits/Deductibles ~'\ <br />Premium <br />Bodily Injury / Property Damage - <br />$1,000,000 Combined Single Limit" $750.00 <br />Combined Single Limit <br />-- <br />Medical Payments — '— -"— "-—$1`0,7]00 Each Person / Each Accident $57.00 <br />Uninsured / Underinsured Motorist $100,000 Combined Single Limit �4� \ Q $111,00 <br />Combined Single Limit �Q <br />-- <br />Total for this Vehicle � $918.00 <br />-- <br />Combined Vehicle Premium �pa��e�. $918,00 <br />Acquisition Expense ��,,` �i�`' $20.00 <br />CA Vehicle Assessment and Fraud Fee ccam�\ r�W $1.76 <br />Total 12 M P4i'Q. temllum $939.76 <br />10039CA(06012014) <br />