Infinity Value Added

Infinity County Mutual Insurance Company

2201 4th Avenue North
Birmingham, AL 35203
Underwritten by: Leader Managing General Agency
Customer Service: (800) 782-1020 Claims Service: (800) 334-1661
PERSONAL AUTO DECLARATION
POLICY NUMBER: 142560488534001

POLICY PERIOD: 09/17/2020 TO 03/17/2021.

LOZADA FERNANDEZ, JOSE A This policy is effective no earlier than the date and time on which the
application is accepted by the Company and shall expire at 12:01 a.m.
5757 GUHN RD on the last day of the policy period shown on the Declarations Page. If
APT 284 the policy is cancelled for nonpayment, it may be continued with or
HOUSTON, TX 77040 without a lapse in coverage, contingent upon valid payment and in
accordance with our underwriting rules.

The following coverages and limits apply to each described vehicle as

shown below. Coverages are defined in the policy and are subject to
the terms and conditions contained in the policy, including amendments
and endorsements. No changes will be effective prior to the time
changes are requested.

# Yr Make - Model Serial Number Comp/Coll # Driver Name Excluded SR22

1 2014 DODG DART 1C3CDFBB3ED802565 N/A / N/A 1 Jose Angel Lozada Fernandez No No
2 2015 FORD F150 1FTEW1EFXFKD20348 N/A / N/A 2 Ma.d Reyes Medellin No No
3 2016 HYUN TUCSON KM8J33A25GU046810 N/A / N/A 3 Jose Angel Lozada Reyes No No

COVERAGES - LIMITS OF LIABILITY PREMIUMS FOR VEHICLES

THE COVERAGE IS APPLICABLE ONLY IF A PREMIUM IS INDICATED VEH 1 VEH 2 VEH 3
Bodily Injury Liability $30,000 each person $60,000 each accident 282 362 348
Property Damage Liability $25,000 each accident 142 206 158
Uninsured Motorist - BI ****REJECTED**** ****REJECTED**** No Cov No Cov No Cov
Uninsured Motorist - PD ****REJECTED**** ****REJECTED**** No Cov No Cov No Cov

PREMIUM BY VEHICLE: 424 568 506

TOTAL VEHICLE PREMIUM $1,498.00

MV CRIME PREV AUTH $6.00
OTHER POLICY FEES $15.00
TOTAL POLICY PREMIUM $1,519.00

SEE REVERSE FOR ADDITIONAL INFORMATION

SEE YOUR POLICY FOR COVERAGE DESCRIPTIONS*
Part A - Liability Coverage
ENDORSEMENTS MADE A PART OF THIS POLICY: Part B - Medical Payments
14256AE301; 142TNDE01; 14256PVA04; 142AMD101; Part C - Personal Injury Protection
Part D - Uninsured/Underinsured Motorist Coverage
14256D1E03 Part E - Coverage for Damage to the Insured Auto
Part F - General Provisions
NOTICE: Your payment includes a $6.00 fee. This fee goes to help fund: (1) auto burglary, theft, and fraud prevention, (2) criminal justice efforts, and (3)
trauma care and emergency medical services for victims of accidents due to traffic offenses. By law, we send this fee to the Motor Vehicle Crime Prevention
Authority (MVCPA).

AMEND DATE: 09/17/2020

142DEC04 ENDORSEMENT: 2-1
 Additional Information:

Please mail all inquiries to:

Agency Information: Infinity Insurance

PO Box 830189
FREEWAY INSURANCE SERVICES OF TEXAS, INC
Birmingham, AL 35283-0189
7711 CENTER AVE STE 200
HUNTINGTN BCH, CA 92647
Please fax all inquiries to:
(800)782-2218

LOSS PAYEE ADDITIONAL INTEREST

Veh Addl Name Veh Addl Name
# Int # # Int #

FOR COMPANY USE ONLY

Version Factors PAY PLAN: 6Pay RCP16

Economy RATE REVISION: 1
PREV. POLICY:

RATING CRITERIA
Driver Factors VEH DRV DRV DRV DRV VEH VEH
All Other Channels # # CLS AGE PTS TERR SYMB
Market Factor 1 2 P 53 0 37 1
Multi-Car 2 1 P 51 0 37 1
3 3 P 23 3 37 19

Vehicle Factors

142DEC04