Form_SCTNID_CTGRY.

IA05196489_DECPAGE

910299699 E 3R23097 INS DECPAGE U POLWHITEFONT PRG3S4XJNGHLUSCAEV7KNSVMGF0001 RPUID TRACWHITEFONT

SSB INS SRVCS

6350 LAUREL CYN BLVD
NORTH HOLLYWOOD, CA 91606

Policy Number: 910299699

Underwritten by:
Progressive Northern Insurance Co
ELIZABETH M SALAZAR CAMPOS August 12, 2021
503 W 8TH ST
Policy Period: May 28, 2021 - Nov 28, 2021
TRAILER D
STORM LAKE, IA 50588 Page 1 of 3

1-888-672-6999
SSB INS SRVCS
Contact your agent for personalized service.

progressiveagent.com
Auto Insurance Online Service

Coverage Summary Make payments, check billing activity, update

policy information or check status of a claim.

This is your Declarations Page 1-800-274-4499

To report a claim.

Your policy information has changed

Your coverage began on May 28, 2021 at 12:01 a.m. This policy expires on November 28, 2021 at 12:01 a.m.
This coverage summary replaces your prior one. Your insurance policy and any policy endorsements contain a full explanation of your
coverage. The policy limits shown for a vehicle may not be combined with the limits for the same coverage on another vehicle. The
policy contract is form 9611A IA (07/16). The contract is modified by forms 4884 (10/08), Z195 (07/05) and A264 (10/18).
Progressive Northern Insurance Co is a stock company (NYSE: PGR).

Policy changes effective August 11, 2021

………………………………………………………………………………………………………………………………………………………..
Changes requested on: Aug 11, 2021 04:57 p.m.
………………………………………………………………………………………………………………………………………………………..
Requested by: Elizabeth M Salazar Campos
………………………………………………………………………………………………………………………………………………………..
Premium change: $0.00
………………………………………………………………………………………………………………………………………………………..
Changes: 414GREEEN STATE CREDIT UNION has been added as an additional interest
on the 2015 JEEP WRANGLER SAHARA.
The changes take effect as of the date and time requested shown above.
Drivers and household residents
Elizabeth M Salazar Campos
Additional information: Named insured
William Talamante JR
Andrea M Salazar
Additional information: excluded driver

Form 6489 IA (05/19)

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Continued
910299699 E 3R23097 INS DECPAGE U POLWHITEFONT PRG3S4XJNGHLUSCAEV7KNSVMGF0001 RPUID TRACWHITEFONT

Policy Number: 910299699

Elizabeth M Salazar Campos
Page 2 of 3

Outline of coverage
2010 TOYOTA TUNDRA CREW PICKUP
VIN: 5TFUW5F19AX120532
Garaging ZIP Code: 50588
Primary use of the vehicle: Commute
Length of vehicle ownership when policy started or vehicle added: Less than 1 month
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $433
Bodily Injury Liability $20,000 each person/$40,000 each accident
Property Damage Liability $15,000 each accident
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Underinsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Total premium for 2010 TOYOTA $433
2008 GMC SIERRA C1500/K1500 CREW PICKUP
VIN: 3GTEK13388G300100
Garaging ZIP Code: 50588
Primary use of the vehicle: Pleasure/Personal
Length of vehicle ownership when policy started or vehicle added: Less than 1 month
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $302
Bodily Injury Liability $20,000 each person/$40,000 each accident
Property Damage Liability $15,000 each accident
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Underinsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Total premium for 2008 GMC $302
2017 GMC CANYON CREW PICKUP
VIN: 1GTG6CEN3H1273443
Garaging ZIP Code: 50588
Primary use of the vehicle: Commute
Length of vehicle ownership when policy started or vehicle added: Less than 1 month
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $259
Bodily Injury Liability $20,000 each person/$40,000 each accident
Property Damage Liability $15,000 each accident
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Underinsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Total premium for 2017 GMC $259

Form 6489 IA (05/19)

4
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910299699 E 3R23097 INS DECPAGE U POLWHITEFONT PRG3S4XJNGHLUSCAEV7KNSVMGF0001 RPUID TRACWHITEFONT

Policy Number: 910299699

Elizabeth M Salazar Campos
Page 3 of 3
2015 JEEP WRANGLER SAHARA 4 DOOR WAGON
VIN: 1C4BJWEGXFL727832
Garaging ZIP Code: 50588
Primary use of the vehicle: Commute
Length of vehicle ownership when policy started or vehicle added: Less than 1 month
Information regarding your vehicle history (prior damage, theft or title issues) has impacted how we determine your premium.
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $355
Bodily Injury Liability $20,000 each person/$40,000 each accident
Property Damage Liability $15,000 each accident
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Underinsured Motorist Rejected --
………………………………………………………………………………………………………………………………………………………..
Total premium for 2015 JEEP $355
………………………………………………………………………………………………………………………………………………………..
Total 6 month policy premium $1,349.00

Premium discounts
Policy
………………………………………………………………………………………………………………………………………………………..
910299699 Electronic Funds Transfer (EFT), Multi-Car, Continuous Insurance: Diamond and
Paperless

Additional interest information

Vehicle Additional interest
………………………………………………………………………………………………………………………………………………………..
2015 JEEP WRANGLER SAHARA 414GREEEN STATE CREDIT UNION
1C4BJWEGXFL727832 NORTH LIBERTY,, IA 52317

Company officers

President Secretary

Form 6489 IA (05/19)