Policy Number: Date of Notice
PO Box 3199 ● Winston Salem, NC 27102-3199 2015471741 08/23/2022 02:20 PM
Named Insured:
NAYTZE REYNOSO
NAYTZE REYNOSO Policy Period:
UNIT 212 6/6/2022 - 12/6/2022
11100 RIVERSIDE DR
NORTH HOLLYWOOD CA 91602 Policy Underwritten By:
NOIBM
Integon National Insurance
Company
24 Hour Claim Reporting: 1-800-468-3466
For Policy Information: 1-877-468-3466
[Link]
Your Agent:
Fiesta Auto Ins Ctr #Ca003
7247 Van Nuys Blvd
Van Nuys CA 91405
(818) 933-5480
CA PERSONAL AUTO DECLARATIONS PAGE
Endorsement Effective 8/23/2022 2:20 PM
The following changes were made to your policy – Coverage(s) Added, Coverage(s) Deleted
INTEGON NATIONAL INSURANCE COMPANY
Drivers and Household Residents
#1 NAYTZE REYNOSO Operator: Principal #1
Driver Status License # Lic. State Date of Birth Gender Marital Status Driver Pts Yrs. Licensed
Rated Driver XXX8226 CA 4/4/1975 Female Single 0 31 US;0 INT'L
#2 Kevin Eghballi Operator: Principal #2
Driver Status License # Lic. State Date of Birth Gender Marital Status Driver Pts Yrs. Licensed
Rated Driver XXX8989 CA 2/24/1997 Male Single 3 9 US;0 INT'L
Accidents/Violations Description
Date:11/7/2019 At-fault accident - no injury
Insured Vehicle(s) and Schedule of Coverages
#1 2015 BMW 320 I VIN: WBA3B1G5XFNT04363-4243
Usage: Pleasure
Estimated Annual Mileage: 18000
Garaging Location: 91602
Coverages Provided Limits / Deductibles Premium
Bodily Injury $15,000 Each Person / $30,000 Each Accident $155.00
Property Damage $10,000 Each Accident $191.00
*SEE IMPORTANT NOTICE SECTION FOR REDUCED LIMITS IN
SPECIFIED SITUATIONS
Uninsured / Underinsured Motorist Bodily Injury $15,000 Each Person / $30,000 Each Accident $40.00
Uninsured Motorist Property Damage $3,500 Each Accident $16.00
Total For This Vehicle $402.00
#2 2016 BMW X1 XDRIV VIN: WBXHT3C35GP881915-4134
Usage: Pleasure
Estimated Annual Mileage: 10000
Garaging Location: 91602
Loss Payee Address
Lobel Financial PO Box 3000, Anaheim, CA 92803
Coverages Provided Limits / Deductibles Premium
10039CA (03012010)
Bodily Injury $15,000 Each Person / $30,000 Each Accident $179.00
Property Damage $10,000 Each Accident $220.00
*SEE IMPORTANT NOTICE SECTION FOR REDUCED LIMITS IN
SPECIFIED SITUATIONS
Uninsured / Underinsured Motorist Bodily Injury $15,000 Each Person / $30,000 Each Accident $50.00
Other Than Collision $1,000 Deductible $123.00
Collision $1,000 Deductible $413.00
Collision Deductible Waiver $1000 Deductible Waiver $12.00
Total For This Vehicle $997.00
Combined Vehicle Premium $1,399.00
CA Vehicle Assessment and Fraud Fee $0.88
CA Vehicle Assessment and Fraud Fee $0.88
Policy Fee $26.80
Total 6 Month Policy Premium $1,427.56
Discounts Applied
Policy Level
Multi-car Discount
Vehicle Level
#1 Anti-lock Brakes Discount
#2 Anti-lock Brakes Discount
#2 Anti-theft Discount
#1 Passive Restraint Discount
Driver Level
#1 Good Driver Discount
#2 Good Driver Discount
Important Notice
NOTE: THE MAXIMUM AMOUNT PAYABLE FOR BODILY INJURY AND PROPERTY DAMAGE UNDER THE LIABILITY COVERAGE PART
A OF THIS POLICY SHALL BE $15,000/$30,000/$5,000 FOR DRIVERS NOT LISTED IN THE DECLARATIONS AND UNDER SPECIFIED
SITUATIONS SET FORTH IN THE POLICY AND ENDORSEMENTS.
CONTINUING DUTY TO INFORM AS A CONDITION OF COVERAGE UNDER THE POLICY
In order to maintain the coverage described in this policy, the Named Insured has a continuing duty to
notify the Company of ANY changes concerning the following: (1) the garaging location of the listed
vehicle (s) on the policy (ies); (2) member (s) of the Named Insured’s household age 14 years and older;
(3) operator (s) of the listed vehicle (s) on the policy; (4) the usage of the listed vehicle (s) on the policy
and 5) marital / domestic partnership status within 30 days of such change. The Named Insured
understands and agrees that this information is material to the risks insured and that the insurance
company may rescind this policy or deny coverage if the Named Insured fails to notify the company of
these changes prior to a loss.
EL DEBER CONTINUO DE INFORMAR COMO CONDICIÓN DE COBERTURA BAJO LA POLIZA
Para mantener la cobertura descrita en esta Póliza, el Asegurado tiene el deber continuo de notificar a la
Compañía de CUALQUIER cambio relacionado con lo siguiente: (1) la ubicación del garaje de los
vehículos enumerados en la (s) póliza (s); (2) miembro (s) de la casa del asegurado de 14 años o más de
edad; (3) operador (es) de los vehículos enumerados en la Póliza,; (4) el uso del (de los) vehículo (s)
enumerados en la póliza y 5) el estado marital o conyugal dentro de los 30 días posteriores al cambio. El
Asegurado designado entiende y acepta que esta información es importante para los riesgos asegurados
y que la compañía de seguros puede rescindir esta póliza o denegar la cobertura si el Asegurado
designado no notifica a la compañía de estos cambios antes de una pérdida.
If you are a member of a motor club, an RV club, a professional association, an employee
group or other similar type group and would like your policy reviewed to assure you are
receiving the best possible rate, please contact your agent or the company.
10039CA (03012010)
