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National General <br />A,t . Home & Health msu,aa,x <br />PO Box 3199 - Winston 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 />5/2112018 - 5121 /2019 <br />Date of Notice: 6/21/2018 <br />Policy Underwritten By: <br />Integon National <br />Insurance Company <br />24 Hour Claim Reporting: 1.8004683466 <br />For Policy Information: 1.877468-3466 <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 5/21/2018 <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 <br />Date of Birth Gender Marital Status <br />Driver Pts Yrs. Licensed <br />Owner Driver XXX9358 CA <br />10/26/1967 Male Married <br />0 44 <br />#2 Jennifer L Bystry <br />Driver Status License # Lic State <br />Date of Birth Gender Marital Status <br />Driver Pis Yrs. Licensed <br />Relative CA <br />2/6/1978 Female Married <br />0 24 <br />Excluded <br />Insured Vehicle(s) and Schedule of Coverages <br />#1 2011 HOND ELEMENT LX <br />VIN: Usage: Personal Use Radius: 0 <br />SJ6YH1H326L003266- Only <br />BD3335 <br />Garaging Location: <br />92780 <br />Policy Coverage Level <br />ScheduledAuto <br />Coverages Provided <br />Limits/DeductIbIas <br />Premium <br />Bodily Injury / Property Damage - <br />Combined Single Limit <br />$1,000,000 Combined Single Limit <br />$910.00 <br />Medical Payments <br />$10.000 Each Person / Each Accident <br />$65.00 <br />Uninsured / Underinsured Motorist <br />$100,000 Combined Single Limit <br />$109.00 <br />Combined Single Limit <br />Total for this Vehicle $1 084.00 �1 <br />e <br />10039CA(06012014`, <br />p�G <br />