PROOF OF INSURANCE (2023) CLOSEDNamed Insured and Mailing Address
MICHAEL K STENSTROM
3032 MOTOR AVE
LOS ANGELES, CA 90064-4741
E-mail: STENSTRO@SEAS,UCLA.EDU
PERSONAL AUTO RENEWAL
POLICY DECLARATION EFFECTIVE 01/17/23
Account:
21ST CENTURY INSURANCE
Customer Service Center:
21st CENTURY INSURANCE
21ST CENTURY PLAZA
P.O. BOX 15510
WILMINGTON, DE 19850-5510
Policy No: 135 28 34
Policy Period: From 01/17/23
To: 07/17/23 12:01 AM Standard Time
Vehict s) "and Drly s _
m �)
VMake/Model
use Vehicle DiscounWCommerft Zip Mileage
°
h 15 MERZGL4504MATIC�UT� Vehicle iD>4umber _ ���P MCDIGD � � 90064 4,000
4 2 18 MERZ C 434MATIC AMG CV P MCD\GD 90064 12,000
i
Veh Rated Driver L mews d!YeTickets Chargeable Accidents Driver Discounts
oAIH-,.-,_ ....... ..._ _. _
56._m....�.. O_ .... _a... _....._ GDD\SD5
2 NAMALIGLIG
40 0 GDD\SD5
f
COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE
Coverag . �1Liabiiity
e , Limit of Veh 1 Veh 2
_ Premium
AinclBodil$On138 per vehicle fraud fee 25a, aoo each person
_.....
rY Liability P
_�. P ._�-�................_ ..� $500, 000 _ each accident w .,,_.., $ 221.00 $ 203.00
„8. Prope mDamage Llablllt �. $200, 000 each accident $ 115.00 . $ mmmmm 142.00___
C. Medical Payments $5, 00a...__ each�erson 16,00 s 34 on,
....� q _. .,..__ person,
.39.00. -.....
Uninsured Motorist : $250, 000 each erson
I , Bodily d"sqy Nnjl r s�oo, aoo each accident ... $ 72.00
DAMAGE TO YOUR VEHICLE Veh 1 Veh 2
Actua... ........ .._
I Cash Value Less Deductible Ded. Ded.
. ..._ ... ....-
E Comprehensive ....0 09.00 $ 145.00
$> ace $>50 $
F Collision $500 _. $500 .$ 195.0 �a $ � � 9 a o
_...., � ..
Uninsured Moto I
95 . a
Motorist RIVE G $ 5.00 $ 5.00
a
_. Pra(Se lmae.......................�_.6 �n waly tra sir... _..m _... _..
21 st Century
l G.
Roadside Assistance $75 each disablement Included Included
Rental Per day $5050 "T __.......
C H. Reimburs... ment [max 1 .. $1 e 500 $ 37 0.0 $ 37 .00
e
J. Additional Eqquipment Included $1, 000 $1, 000
The first $10 10 is automatically Additional
included with coverage E or F. Total $1, 000 $1, 000
Additional coverage is o tional $ 0 00 $ 0.00
Total Premium Per Vehicle $ 737 oo $ 1632.00 IIII
.............
.. _......-_.--.9.............__ w
369.00,
_.__.. ___.�.........._...... ....
If the installment bill plan is used, a service charge may apply. Total Premium $ 22
ndorsement s /A reement s Ap li" abl .. ...._ _.._.
_ () g () pplicable:
=PN-CA (1/20) TCU-1 (01/19)
rCU511CA (05/18) TCU531CA (02/12)
\U CWF9 1011
Loss Payee (LP), Additional Insured (AI) Drivers Not Rated
Veh 1 LP MERCEDES BENZ FIN
Veh 2 LP USC CREDIT UNION
12/12/22
THE FOLL00,NG FEE(S) MAY APPLY:
LATE: $5.00 PAYMENT RETURNED (NSF): $10.00
CANCEL: $60.00 INSTALLMENT BILL PLAN SERVICE CHARGE14.00
Authorized Company Representative (where required)
WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT
THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY.
Visit 21st.com to make policy changes, pay your premium, and more. Register online today! For Customer Care call 800-241-1188.
TCU4ICA (12/14) 21st Century Insurance Company, P.O. Box 15510, Wilmington, DE 19886-5292