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•: StateFarm <br /> Other Household Driver(s) <br /> In addition to the Principal Driver(s)and Assigned <br /> Driver(s),your premium may be influenced by the <br /> drivers shown below and other individuals permitted to <br /> drive your vehicle. This list does not extend or expand <br /> coverage beyond that contained in this automobile <br /> policy. The drivers listed below are the drivers reported <br /> to us that most frequently drive other vehicles in your <br /> household. <br /> YA5MIN GUTIERREZ <br /> It is your responsibility to inform us of all regular For business related vehicles, also include the <br /> drivers of your vehicles and changes to those drivers business owner(s)and employee(s)that drive the <br /> throughout the life of your policy. Failure to disclose vehicle(s)in any capacity <br /> drivers may result in denial of coverage. Regular Principal Driver&Assigned Drivers <br /> drivers, regardless of their relationship to the primary For each automobile,the Principal Driver is the individual <br /> named insured or their residence address, include: who most frequently drives it. <br /> • All drivers who drive the vehicle(s)on the policy Each driver is designated as an Assigned Driver on the <br /> once or more in a typical month household automobile that they most frequently drive.Your <br /> • All drivers who regularly drive the vehicle(s)at premium may be influenced by the information shown for <br /> least three months of the year these drivers. <br /> COVERAGE AND LIMITS See your policy far an explanation of these coverages. <br /> A Liability <br /> Bodily Injury 100,0001300,000 <br /> Property Damage 50,000 $222,46 <br /> C Medical Payments 10,000 $18.97 <br /> D Comprehensive $44.58 <br /> G 250 Deductible Collision $106.63 <br /> H Emergency Road Service $4.51 <br /> U Uninsured Motor Vehicle <br /> Bodily Injury 100,000/300,000 $51.84 <br /> U1 Uninsured Motor Vehicle <br /> Property Damage $2.20 <br /> Total Premium $451.19 <br /> If any coverage you carry is changed to give broader you the broader protection without issuing a new policy, <br /> protection with no additional premium charge, we will give starting on the date we adopt the broader protection. <br /> DISCOUNTS These adjustments have already been applied to your premium. <br /> Multiple Line <br /> (continued on next page) <br /> Policy Number:C17 1868-005-05H Page number 3 of 5 <br /> Prepared January 12,2026 <br />