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•^"REPRINTED FROM THE ARCHIVE. THE ORIGINAL TRANSACTION MAY INCLUDE ADDITIONAL FORMS •"' <br />InsuranceT4 <br />~~~~ <br />POLICY NUMBER: UA3442004 <br />SAFECO INSURANCE COMPANY OF AMERICA <br />PERSONAL UMBRELLA POLICY DECLARATIONS <br />INSURED: AGENT: <br />MAUREEN BASSOON NHC INSURANCE SERVICES INC <br />PO BOX 2028 796 W 9TH ST <br />PALOS VERDES PEN CA 90274-8028 SAN PEDRO CA 90731-3602 <br />{310) 221-0917 <br />RESIDENCE PREMISES: <br />27056 SHOREWOOD RD <br />RCH PALOS VRD CA 90275-2228 <br />POLICY PERIOD FROM: J U N E 2 7 2 009 <br />T0: JUNE 27 2010 <br />at 12:01 A.M. Standard time at <br />the address of the insured as <br />stated herein. <br />RETAINED LIMIT: X250 <br />LIMIT OF LIABILITY: $1 , 000 , 000 <br />SCHEDULE OF UNDERLYING INSURANCE: <br />The insured agrees: <br />1) that insurance policies providing the coverages specified on the back of these declarations, if applicable, <br />are in force and will be maintained in force as collectible insurance for at least the required minimum <br />limits stated <br />2) to insure all motor vehicles owned, leased by or used by the insured <br />3) to insure all residence premises owned, leased by or leased to the insured <br />4) to insure all recreational vehicles owned, leased by or used by the insured <br />5) to insure all watercraft owned by the insured <br />COVERAGES PREMIUM <br />Basic premium - includes one automobile and primary residence ~ 206.00 <br />In Home Business Coverage $ 30.00 <br />1 Additional automobile in the household $ 79.00 <br />2 Rental units ~ 26.00 <br />TOTAL ANNUAL PREMIUM $ 341.00 <br />You can pay your premium in full or in installments. If you pay in installments <br />using automatic deduction, no installment fee will apply to each installment. If <br />you pay in installments without using automatic deduction, a $2.00 installment fee <br />will apply to each installment. If there is more than one policy billed on the <br />installment bill, only the highest fee amount would be applied to the bill. <br />PLEASE SEE REVERSE <br />ORIGINAL DATE PREPARED APR. 28 2009 <br />P-1075/E P 9/06 <br />G1 <br />