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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: 1-877-468-3466 <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 5121/2019 <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: <br />5J6YH1H32BL003266- <br />BD3335 <br />Garaging Location: <br />92620 <br />Policy Coverage Level _ - <br />— _ ScheduledAuta <br />Coverages Provided <br />C Bodily Injury / Property Damage - <br />Combined Single Limit <br />Medical Payments <br />Uninsured / Underinsured Motorist <br />Combined Single Limit <br />Usage: Personal Use Radius:0 <br />Only <br />Limits/Deductibles <br />$1,000,000 Combined Single Lim# <br />$10,000 Each Person / Each Accident <br />$100,000 Combined Single Limit <br />Total for this Vehicle <br />Combined Vehicle Premium <br />Acquisition Expense <br />CA Vehicle Assessment and Fraud Fee <br />Total 12 <br />e <br />J\ <br />Premium <br />$750.00 <br />$57.00 <br />$111.00 <br />$918.00 <br />$918.00 <br />$20.00 <br />$1.76 <br />$939.76 <br />10039CA (06012014) <br />