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86698.4-P MATCH 00534 MUTL VOL <br />Statelerm State Farm Mutual Automobile Insurance Company <br />B PO Box 853922 <br />Richardson, TX 75085-3922 <br />NAMED INSURED 00534 <br />75-7501-4 P <br />Dose <br />NANCY K COUNSELING <br />IoNGu <br />DNA THE COUNSELILI <br />NG TEAM <br />INTERNATIONAL <br />PO BOX 10427 <br />SN BERNRDNO CA 92423-0427 <br />DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. <br />IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED. <br />DECLARATIONS PAGE <br />PAGE 1 OF 2 <br />POLICY NUMBER 4414187-F2475W <br />POLICY PERIOD) 11 OCT 31 2019 to JUN 24 2020 <br />12 01 A M Standard Time <br />AGENT <br />SKALA INSURANCE AGENCY INC — <br />4214 N SIERRA WAY <br />SN BERNRDNO, CA 92407-3896 _ <br />PHONE: (909)883-8861 <br />rvun UAn <br />YEAR MAKE MODEL BODY STYLE VEHICLE ID, NUMBER <br />2017 BMW X5 SPORT WG 5UXKR6036HOU13705 600HCV11 <br />SYMBOLS <br />COVERAGE 6 LIMITS <br />PREMIUMS <br />A <br />Liability Coverage <br />$702.61 <br />Bodily Injury Limits <br />Each Person, Each Accident <br />$1,000,000 $1,000,000 <br />Property Damage Limit <br />Each Accident <br />$1,000,000 <br />D <br />Comprehensive Coverage-$1,000 Deductible <br />$139.21 <br />G <br />Collision Coverage-$1,000 Deductible <br />$508.25 <br />R1 <br />Car Rental and Travel Expenses Coverage <br />$44.33 <br />Limit - Car Rental Expense <br />Each Day, Each Loss <br />$50 $1 A00 <br />U <br />Uninsured Motor Vehicle Coverage <br />$75.91 <br />Bodily Injury Limits <br />Each Person, Each Accident <br />$100,000 $300,000 <br />Ut <br />Uninsured Motor Vehicle Property Damage Coverage <br />$10.37 <br />Additional Use of Non -Owned Car Coverage <br />BIPD Liability <br />$5.18 <br />Physical Banner- <br />S25 88 <br />Total Premium for OCT 31 2019 to JUN 24 2020,- $1 511.74 Thls is not a bill. <br />IMPORTANT MESSAGES <br />Replaced policy number 4414187-75V. <br />Your total renewal premium for DEC 24 2019 to JUN 24 2020 is $1,160.84. <br />Location used to determine rate charged-36442 WILDWOOO CANYON RD, YUCAIPA CA 92399.5274. <br />CONTINUED <br />06813/07236 See Reverse Side <br />I5 W66C 2 %2002 IoinWW-) <br />II S%ON Ia1.M.) <br />,6W91J-k) <br />