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0912W209 MIUM190 RW 9rfli I I a9 MI0699199 <br />TEPA INSURANCE SERVICES INC - 001 <br />2509 W MCFADDEN AVE STE G <br />SANTA ANA, CA 92704 <br />(714)835-5159 <br />Named Insured <br />VICTOR J SANDOVALLOPEZ <br />2132 S ROSS ST <br />SANTA ANA, CA 92707-2717 <br />undefW,irten By: <br />Alliance United Insurance Services, LLC <br />Al <br />P,O. Box 6060, Camarillo, CA 93011 -6060 <br />Ph:(866) 530.5500 Fax:(866) 530.2500 <br />Alliance United <br />Inswanw fampany <br />Lic It OC17987 www.allianceunited.com <br />REWRITE DECLARATIONS PAGE <br />Online Auto Rewrite of Cancel - Producer Payment <br />Policy Number: <br />Effective Date: <br />Expiration Date: <br />VEHICLE INFORMATION <br />MIL3689190 5 <br />09/22/2017 12:31 PM PT <br />03/22/2018 12:01 AM PT <br />Veh # Year Make Model VIN mileafle Use Symbol Driver <br />1 2006 CHEV EXPRESS G3500 1GAHGSSU061270014 16500 Pleasure W-15-15 1 <br />COVERAGE AND PREMIUM INFORMATION <br />BI $15,000 Each Person / $30,000 Each Accident $107,75 <br />PD $10,000 Each Accident $111.59 <br />Total Vehicle Premium: $it 9.34 <br />Rewrite Fee $10.40 <br />Anti -Fraud Feels) $0 87 <br />Total Premium and Fees $230.61 <br />DRIVER INFORMATION <br />Driv Name <br />Gender Marital DOB <br />Yrs Lic Relation <br />License # Points <br />1 VICTOR J SANDOVALLOPEZ <br />M M 07/XX/1979 <br />22 Self <br />XXXX5004 1 <br />2 MADE JESUS SANDOVAL <br />F M 04/XX11980 <br />21 Spouse <br />XXXX5894 0 <br />EXCLUDED DRIVER INFORMATION <br />Name <br />Bancor Marital <br />Q <br />Relation <br />JACOB SANDOVAL <br />M S <br />10/XX/1988 <br />SON <br />DAVID SANDOVAL <br />M S <br />03/XX/1989 <br />BROTH <br />DRIVING RECORD <br />Drbv# Description Date Points <br />1 22102 Turning/Turn Signals 03/31/2016 1 <br />1 5201 Registration 03/31/2016 0 <br />OISCOUNTSISURCHARGES <br />Description Veh #1 <br />Multi-Car/Driver Discount X <br />Good Driver Discount „t `I X <br />Anti -Fraud Fee �f✓� b 7 X <br />�Aevas <br />