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----------- --- -- <br /> PC)LIC.Y DECLA RATI ONS <br /> NEW POLICY <br /> pulit: CALIFORNIA LOW COST POLICY <br /> — <br /> Polio Number:CAR 5006 08 16 <br /> Insurer: 21st Century Centennial Insurance Co <br /> 01 <br /> CA Automobile Insurance Plan Issuing Company Address <br /> C. A.I.P. Case No.: 202520900599 ATTN: BW Assigned Risk <br /> o PO Box 248983 <br /> The Policy Period Begins and Ends at 12:01 A.M. Oklahoma City, OK 73124-8983 <br /> Standard Time From 07/25/25 To 07/25/26 <br /> 0 <br /> a Effective Date of Change: 07/25/25 Producer : <br /> Co HUSSEIN ABUBAKER <br /> o Named Insured: 520 N BROOKHURST ST <br /> MAGALI A ALARCON CANCINO STE 113 <br /> 702 S EMILY ST ANAHEIM, CA 92801-5232 <br /> ANAHEIM, CA 92805-4735 1-714-882-5060 <br /> ST. 04 CO: 0054 ACCT. 00013000 <br /> DESCRIPTION OF YOUR COVERED AUTO(S): Pointe/ <br /> AUTO TERR SYMBOL AGE YR MAKE-MODEL SERIAL NUMBER CLASS Surcharge <br /> 1 47 37 33 11 15 BMW X3 5UXWZ7C56FOM83453 9LZ 000 <br /> COVERAGE IS ONLY PROVIDED WHERE A SPECIFIC PREMIUM CHARGE IS SHOWN <br /> COVERAGE LIMITS OF LIABILITY AUTO 1 <br /> Bodily Injury. . . . . . . . . . . . . .$10,000/$20,000 Per Person/Accident $ 648.00 <br /> Property Damage. . . . . . . . . . . .$3,000 Per Accident INCL <br /> Total Premium Per Auto $648.00 <br /> TOTAL FULL TERM PREMIUM $648 .00 <br /> When a Low Cost Auto Policy is cancelled, the premium refund will be determined based on the pro rata unearned premium <br /> for the period of coverage, subject to a minimum premium of$50 per policy. <br /> APPROVED <br /> By Tu Tran Nguyen at 9:53 am,Sep 29,2025 <br /> Tu Tran Digitally signed by <br /> Tu Tran Nguyen <br /> Date:20 <br /> Nguyen 095341-0700'9 <br /> •�nl_ <br /> Authorized Company Representative(where required) <br /> 01 08/13/25 Page 1 of 2 Form AR D-105(1/06) <br />