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National General <br />Auto. Mom! A HoAh Iniuran¢ <br />PO Box 3199 • wlnston Salem. NC 27102-3199 <br />THOMAS E BYSTRY <br />16875 DONWEST <br />TUSTIN CA 92780 <br />Policy Number: 2006521219 <br />Named Insured: <br />Thomas E Bystry <br />videotb@aol.com <br />Policy Period: 1:32 PM <br />5121/2018.6/21/2019 <br />Date of Notice: 6/21/2018 <br />Policy Underwritten By: <br />Integon National <br />Insurance Company <br />24 Hour Claim Reporting: 1-800r468.3466 <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 Suite P <br />Santa Ana CA 92705 <br />(714)884-4284 <br />CA COMMERCIAL VEHICLE DECLARATIONS PAGE <br />Endorsement Effective 612112018 <br />The following changes were made to your policy - Driver Information Updated <br />Drivers, Employees and Household Residents <br />#1 Thomas E Bystry <br />Driver Status License # Lic State Date of Birth Gender <br />Marital Status <br />Driver Pts <br />Yrs. Licensed <br />Owner Driver XXX9358 CA 10/2611957 Male <br />Married <br />0 <br />44 <br />#2 Jennifer L Bystry <br />Driver Status License # Lic State Date of Birth Gender <br />Marital Status <br />Driver Pts <br />Yrs. Licensed <br />Relative CA 2/6/1978 Female <br />Married <br />0 <br />24 <br />Excluded <br />Insured Vehicle(s) and Schedule of Coverages <br />#1 2011 HOND ELEMENT LX VIN: <br />Usage: Personal Use Radius: 0 <br />5J6YH1H326L003266- <br />Only <br />BD3335 <br />Garaging Location: 92780 <br />Policy Coverage Level ScheduledAuto <br />r'- <br />Coverages Provided Limits/Deductibles Premium <br />Bodily Injury I Property Damage - �$1,000,000 Combined Single Limit $910,00 <br />Combined Single Limit <br />Medical Payments $10,000 Each Person / Each Accident $65.00 <br />Uninsured / Underinsured Motorist $100,000 Combined Single Limit $109.00 <br />Combined Single Limit <br />Total for this Vehicle $1 084.00 <br />ed <br />10039CA(D6012014; c\\J C,\Ne o- <br />��C, <br />