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BGT40026546
FERNANDO DELGADO
06-29-2013
DO NOT SEND REQUEST FOR THIS ENDORSEMENT NOR COPY OF PRINTED ENDORSEMENT TO NEWPORT GENERAL AGENCY. Step 1: Ensure that the following items have printed: Endorsement ID Card(s) Give the insured their copy of the: Endorsement ID Card(s) Retain a copy of the following for your records: Endorsement
Next installment payment of approximately $43.43 is due by 06/27/2013.
Step 2:
Step 3:
Installment amounts were figured based on amount of endorsement down receipted. If payment already submitted for the installment due date shown, pay the difference in amount shown and amount already submitted. A $5 late fee will be applicable if the payment is postmarked after the due date. POLICY PENDING CANCELLATION FOR NON PAY EFFECTIVE 07-08-2013 AND WILL NOT BE REINSTATED UNLESS ITEM(S) REQUIRED FOR REINSTATEMENT WERE PROVIDED TO COMPANY PRIOR TO CANCELLATION EFFECTIVE DATE. BINDING THIS ENDORSEMENT AND RECEIPTING MONIES FOR IT DO NOT CONSTITUTE REINSTATEMENT.
INSTRCT_NEWPRT (2012/12)
Endorsement
#19
Policy Number: BGT40026546 Company: OLD AMERICAN COUNTY MUTUAL FIRE Endorsement Effective Date: 06-29-2013 12:28:30 Policy Expiration Date: 12-07-2013 Insured:
INS CO PM CDT
06-29-2013
12:28:30 PM CDT
FERNANDO DELGADO 13631 TIMBER WEST LN CONROE, TX 77304-4717 Policy Change Summary
Cancelled vehicle # 3 2000 DODGE NEON HIGHLINE/NEON ES 1B3ES46C4YD502718. Added vehicle # 5 1996 CHEVROLET PICKUP 1500 2GCEC19W4T1209440. ****POLICY PENDING CANCELLATION FOR NON PAY EFFECTIVE 07-08-2013 AND WILL NOT BE REINSTATED UNLESS ITEM(S) REQUIRED FOR REINSTATEMENT WERE PROVIDED TO COMPANY PRIOR TO CANCELLATION EFFECTIVE DATE. BINDING THIS ENDORSEMENT AND RECEIPTING MONIES FOR IT DO NOT CONSTITUTE REINSTATEMENT.
The Auto(s) or Trailer(s) described in this policy is principally garaged at the above address unless otherwise stated: DRIVERS Dvr Name Class Pts Dvr Name Class Pts
FERNANDO DELGADO
ER
CN
3 4 5
** 40 40
** 12/12 10/10
** 2 1
W2 W2
Any loss under Part D is payable as interest may appear to the named insured and (include name and address)
Auto
Name
Address
City
State
Zip Code
COVERAGE Bodily Injury Liability Property Damage Liability Uninsured/Underinsured Motorists BI Uninsured/Underinsured Motorists PD
($250 Deductible Applicable to Property Damage Liability)
LIMITS
30,000 Each Person 60,000 Each Accident 25,000 Each Accident
PREMIUM CHANGE
99.00 76.00
-4.00 -3.00
Each Person Each Accident Each Person Each Person Each Person
Multi-Car Renewal
MC RN
Premium Due To Change:
-7.00
Form numbers for endorsements attached to policy: 515A, 551, OACM.CRIMEINTENT.008, OACM.PHYSDAM.001, OACM.YCA.002, OACM.AUTHDRIV.003A, OACM.STORAGE.004, OACM.DELFEE.005, OACM.CONTLIAB.006, OACM.AUTOTERM.007, OACM.CP.013B, OACM. OUTOFSTATE.016A, OACM.RENTPROP-NOAUTO.019 P/R Factor: 0.880
Endorsement #19
Attachment Policy Number : BGT40026546 Insured Name : FERNANDO DELGADO EL FARO MULTISERVICES Producer : Policy Period : to 06-07-2013 12-07-2013
NEW 6 MO. PREMIUM: _____________________________________________________________________________________ VEH DEDUCTIBLE BI PD MP OTC COL UMBI UMPD PIP SE RENT TOW TOTAL 4 0/ 0 56 43 0 0 0 0 0 0 0 0 0 99 5 0/ 0 43 33 0 0 0 0 0 0 0 0 0 76 _____________________________________________________________________________________ TOTAL 99 76 0 0 0 0 0 0 0 0 0 175 PREMIUM CHANGE: VEH BI PD MP OTC COL UMBI UMPD PIP SE RENT TOW TOTAL 3 -51 -39 0 0 0 0 0 0 0 0 0 -90 4 9 7 0 0 0 0 0 0 0 0 0 16 5 38 29 0 0 0 0 0 0 0 0 0 67 _____________________________________________________________________________________ TOTAL -4 -3 0 0 0 0 0 0 0 0 0 -7
END-OF (2012/01)
BGT40026546
Insured Name :
FERNANDO DELGADO
This acknowledgement and rejection is applicable to all renewals issued by the Company or any affiliated insurer. You also agree that the insurance coverage afforded by this policy shall not apply while: Name: GUADALUPE FIGUEROA DOB: 12-12-1984 Relation: WIFE the EXCLUDED DRIVER(S) is operating your covered auto or any other motor vehicle. You further agree that this endorsement will also serve as a rejection of Uninsured / Underinsured Motorist Coverage and Personal Injury Protection Coverage while your covered auto or any other motor vehicle is operated by the excluded driver. I, the above named insured, do hereby state that if one of the above named excluded persons is my legal spouse, I agree and understand that by signing below, no coverage will be afforded under this policy to the above named excluded person (spouse).
All other terms and conditions remain unchanged. OLD AMERICAN COUNTY MUTUAL FIRE INS CO Issued on behalf of: Attached to and forming part of policy: BGT40026546 FERNANDO DELGADO Issued to: 06-07-2013 Policy Effective: 06-29-2013 Prepared: NEWPORT GENERAL AGENCY By:
ATTACH (2012/06)
(866) 563-9767
JM1BJ2214X0146225 2GCEC19W4T1209440
BGT40026546
Expiration Date: 12-07-2013 Included Drivers: FERNANDO DELGADO DONNA MARIE BEATY
(866) 563-9767
JM1BJ2214X0146225 2GCEC19W4T1209440
BGT40026546
Expiration Date: 12-07-2013 Included Drivers: FERNANDO DELGADO DONNA MARIE BEATY