Poliza de auto

Access General Insurance Company C/O Access General Insurance Agency of California, Inc. P.O. Box 105866 Atlanta, GA 30348-5866

Underwriting Information Please Complete and Retain the Following Documentation
Policy: Endorsement: Completed: Effective: Insured:

ACA001923284 WE0001043024 6/21/2011 6/22/2011
Producer:

Camilo Rodriguez-Jimenez 1532 Swal St Livingston, CA 95334
EndorsementDetails:

Edmar Insurance Services 1236 West 13th Street Merced, CA 95341

1 - Deleted Vehicle, 2000 PONTIAC GRAND AM 2 - Deleted Coverage, 2000 PONTIAC GRAND AM's BODILY INJURY 15,000 Per Person 30,000 Per Accident 3 - Deleted Coverage, 2000 PONTIAC GRAND AM's PROPERTY DAMAGE 10,000 Each Accident
The following required documentation must be completed and retained in your office. AccessGeneral Insurance Company reserves the right to audit this policy file for completeness and accuracy and request a copy of this or any other policy document. Failure to provide the requested documentation within 72 hours of the request may result in the cancellation or nonrenewal of the aforementioned policy.

No Additional Documentation Required

By signing below you are verifying that the aboveendorsement is correct and that you will provide any documents required by our underwriting department to process this endorsement.

Insured Signature: Producers:
June 21, 2011

Date:

Log on to producer section of http://www.accessgeneral.com/ and click on Forms & Supplies to obtain blank copies of required forms.
Page 1 of 7

Access General Insurance Company C/O Access GeneralInsurance Agency of California, Inc. P.O. Box 105866 Atlanta, GA 30348-5866

Online Endorsement Payment Receipt
Policy: Endorsement: Completed: Effective: Insured:

ACA001923284 WE0001043024 6/21/2011 6/22/2011
Producer:

Camilo Rodriguez-Jimenez 1532 Swal St Livingston, CA 95334
Description of Charges

Edmar Insurance Services 1236 West 13th Street Merced, CA 95341

Policy Endorsement 1 -Deleted Vehicle, 2000 PONTIAC GRAND AM 2 - Deleted Coverage, 2000 PONTIAC GRAND AM's BODILY INJURY 15,000 Per Person 30,000 3 - Deleted Coverage, 2000 PONTIAC GRAND AM's PROPERTY DAMAGE 10,000 Each Accident
Total Payment Received Remaining Premium

IF YOUR PAYMENT IS MADE BY CHECK, DRAFT OR OTHER ORDER OF PAYMENT, AND PAYMENT IS NOT HONORED UPON FIRST PRESENTATION FOR PAYMENT, YOUR COVERAGE WILLBE NULL AND VOID, AND YOUR INSURANCE WILL CEASE.
June 21, 2011 Page 2 of 7

Underwritten by:
Access General Insurance Agency of California, Inc.

Broker: Edmar Insurance Services 1236 West 13th Street Merced, CA 95341 (209) 390-4052
Make payments or check policy information

www.accessgeneral.com

Camilo Rodriguez-Jimenez 1532 SWAL ST LIVINGSTON, CA 95334

Automated service 24 hoursa day / 7 days a week (800) 817-8017 Claims Service (866) 747-6931

PERSONAL AUTO POLICY DECLARATIONS
STANDARD-ENDORSEMENT - EFFECTIVE DATE - 6/22/2011

Policy Number: ACA001923284 Camilo Rodriguez-Jimenez Named Insured: Application Number: FSC2817275 DRIVER(S) LISTED
Camilo Rodriguez-Jimenez Camilo Perez Rodriguez

Policy Period: 02/25/2011 - 02/25/2012
at 12:01 a.m. Pacific TimeDRIVER(S) EXCLUDED
Rosario Torrabla Hernandez Rayna Guadalupe Hernandez

VEHICLES COVERED
1 2000 FORD LGT CONVTNL F

VEHICLE ID NUMBER
1FTZX1724YKA94819

LIENHOLDER
None

PREMIUM
Premium for 2000 FORD LGT CONVTNL F $237.00

TOTAL

$237.00

Administered by: Access General Insurance Agency of California, Inc.
Additional information is available on the internet at:www.accessgeneral.com La informacion adicional esta disponible en el internet en: www.accessgeneral.com Page 1 of 2 Form ACA 1001 (06/10)

Policy Number: Named Insured: Policy Period:

ACA001923284 Camilo Rodriguez-Jimenez 02/25/2011 - 02/25/2012 at 12:01 a.m. Pacific Time

Broker:

Edmar Insurance Services (209) 390-4052

POLICY COVERAGES AND LIMITS
COVERAGE Liability Insurance • Bodily Injury LIMITS...