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<br />e5/23/2011 88:37
<br />
<br />9545775412
<br />
<br />RAV PALHEGVI rHSURAN
<br />
<br />PAGE 62
<br />
<br />flIIIcy nllll\bel: 03)78109-5
<br />AM DRAlNAGEANOVAC
<br />Page 2 of 4
<br />
<br />OuiIIne at canrage
<br />0MllIpIbI liInIt ~ ,......,
<br />uabiiiiY'fo........... ...n..'.. ......, ..... ........... ...... ............ ..........' ,........ ....,... ............., ...... ......................,..... '.. $7:,'34
<br />
<br />...~~.~~':Y.~.~.~~.~.....,....~~!~~:~.~~.~,~,..............,.,.....................................,.
<br />liiled Auto liabilil'( To Olfm 189
<br />...~tl.~~.~.~~~.~~.~~..........~.~!~~~.~~~.~r.~............................................,.............
<br />Emplayllr NorH)wntd AulD Uability To OthelS 67
<br />...~~.~ryl~',~.~~.~.~~.,~I~............~.~~!~.~~~,~~.~!J,~..........................................................
<br />Uninslftd MdOIl5t Non-Stacbd S 1,000,000 mmblned single limlt 1,998
<br />easi( .Pi!i5Oiili'in)iij'~....,.... ,............. ........ ...... ...... ........... ........... ......... ... ........... ............ .......................... '999
<br />
<br />Witholt Wodt c:omp.NanIed k1sultd 0nIJ $10,DOO each peISOII $0
<br />NiediGii pay.............. ....-..... ........... ......... "$5]00' eidl' pe.so7i.... ...... ........... .......... ...m. ........ .......................... liD
<br />
<br />RieAnrrthiiflwtiii cOiilliiiie4f'Addmoiiiiic:o.m.a"._............. ......... ,..................... ................. ..............,.. .-.......... ... '(582
<br />...~~.~~.~~~~~.~~~.~..............................1;!~~!~~,~.~.~~~. ......................,............................... ......
<br />Collision 1,380
<br />See Auto Cowrage Sc:hedufe Ulit of IIablIlty Ie55 decb.t1'blll
<br />
<br />
<br />~.~~~~...............................,........................m......................_......................._.........~.~~~
<br />
<br />~~,~,~,~..9'~~~.~......,....................................................................,..._.....................~~:l~
<br />hs l~OO
<br />TGiiii"2 'iiiOiii' p.Hi:,"piiiiii:iiiii .iiiiii'feti................,..,........ ... ,... .... ..... .... ...... ........................... ... ...... 'S1t1Jll'!
<br />w'liliiiiiiiii',..,..;:;~~ 'iiiidfliiS" ..........-.,....,................ .....' ........ ......... w.....,...... ...,.... ........ 'StU5i:1J
<br />
<br />Number of Employees: (0. 10)
<br />Cost of Hire: $5.000 or less (If any)
<br />
<br />Rated driHn
<br />
<br />.........................................................................n.........................................................................................,..............
<br />
<br />1. JAMESSCRIMA
<br />2. ViiiiiINT sTAMEn.......... ..............,........... ...... ............ .......... ...... ...........,.. ........ ......... ........... .......... ............... ...~
<br />
<br />
<br />Auto GIV4IRIge schedule
<br />
<br />1. 1w.,..m
<br />V1N: 1FDZS9fiK1\WA4147D
<br />
<br />5tatri1 Amount 560,000
<br />Gala9ing Zip CoM: 33D28
<br />
<br />RacllLII: 50
<br />
<br />Uability
<br />Premium
<br />
<br />~............~~........!!........._ .....~~~~~....... ._....... .......... ......... .......... ..........n ..........., ......... ................
<br />$2,996 Sfi66 S46 123
<br />
<br />PhYJiad-Oamage
<br />Premium
<br />
<br />fT/l'.AC FftCM. ClIIllIian ~
<br />~ h!riId l/fttdIIP ~ AIIlo T*
<br />S5OO...........' .sm........... "iSOii..'......... $S94......... ................ ........ .....,.... .........."................ ..... ...,.....$s:1.ii
<br />
<br />2. 1191 Fard WIF
<br />V1N: 1 FOYR82ElWA21025
<br />
<br />Stated Amount 14~.oOO
<br />G.raging Zip Cede: 33028
<br />
<br />RadIus: 50
<br />
<br />Physical Damage
<br />Premium
<br />
<br />~............~.!'!.......,!!................~.......................,......,...............................................................
<br />$2.996 $666 S46 S23
<br />.fT/fX FT,QC CiIIIslan CdsIall
<br />IlIIIIIdiIJlt ~ Ileddle PIIlnIUIII AulVTauJ
<br />$500'" ..........$57'i........ .....$500........... '$476'" ......., ....... ......... ..................... ............................ ......... ~711
<br />
<br />liability
<br />pmnlam
<br />
<br />.
<br />(eoIIftlllll
<br />
<br />1I111"R.~
<br />
<br />...
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