HomeMy Public PortalAboutAuto insurance policy for COTI.pdfAMENDED DECLARATIONS Page of
Changes are Effective
issued by the
()Attached to and forming part of Policy No.12:01 A.M.Standard Time
POLICY PERIOD: 12:01 A.M., STANDARD TIMEFrom:
To:
NAMED INSURED AND ADDRESS
In consideration of premium of we agree that the policy declarations are changed
as follows:
1 3
NONE
CHANGE AUTO 10
SEPTEMBER 19, 2018 99041023BX
APRIL 24, 2018ALAN W. ROBERTSON AND
APRIL 24, 2019MARLA K. ROBERTSON
4 DRIIFTWOOD CT
TYBEE ISLAND GA 31328
Amica Mutual Insurance Company
E-policy Email:MKAWROBERTSON@GMAIL.COM
Auto
No.
The Auto(s) or Trailer(s) described in this policy is principally garaged at the above address unless otherwise stated on the coverage pages.
DESCRIPTION OF AUTO(S) OR TRAILER(S)LOSS PAYEE
1
2
2013 LEXUS RX 350/F SPORT AWD
UTILITY - 4WD
VIN 2T2BK1BAXDC174678
USE:AVERAGE DAILY MILEAGE 10 MILES
2017 LEXUS ES 300H (HYBRID)
SEDAN
VIN JTHBW1GG5H2144562
USE:AVERAGE DAILY MILEAGE 10 MILES
TOYOTA LEASE TRUST
PO BOX 105386
ATLANTA GA 30348
RATES ARE BASED ON THE FOLLOWING HOUSEHOLD DRIVERS
DRIVER'S LICENSE NUMBERNAME
1
2
3
4
5
6
MaleorFemale
MarriedorSingle
Date First
LicensedDate of Birth
Mo.Day Year Mo.YearDriver SAFE DRIVER RATES APPLY.
ALAN W. ROBERTSON
MARLA K. ROBERTSON
059546905
059546919
12
08
08
16
55
55
M
F
M
M
12
08
71
71
Page of
CONTINUATION OF AMENDED DECLARATIONS FOR PERSONAL AUTO POLICY NO.
NAMED INSURED
2 3
10
99041023BX
ALAN W. ROBERTSON AND
MARLA K. ROBERTSON
COVERAGE IS PROVIDED WHERE A LIMIT OF LIABILITY IS SHOWN FOR THE COVERAGE
COVERAGES LIMIT OF LIABILITY
A. LIABILITY
B. MEDICAL PAYMENTS
C. UNINSURED MOTORISTS
D. DAMAGE TO YOUR AUTO (ACV means Actual Cash Value)
GARAGING LOCATION
ACV minus deductible of
ACV minus deductible of
each accident
each person
each accident
each disablement
1. Collision Loss
2. Other Than Collision Loss
TOWING AND LABOR COSTS
OPTIONAL TRANSPORTATION EXPENSES
AUTO 1 AUTO 2
2013 LEXU 2017 LEXU
$ 500,000
$ 5,000
* $ 500,000
$ 1,000
$ 500
$ 500,000
$ 5,000
* $ 500,000
$ 1,000
$ 500
AUTO 1 AUTO 2
*UM ADD-ON TO AT-FAULT-NOT SUBJECT TO DEDUCTIBLE
IN GARAGE
IN GARAGE
4 DRIIFTWOOD CT TYBEE ISLAND GA 31328
4 DRIIFTWOOD CT TYBEE ISLAND GA 31328
1-
2-
*
This policy shall not be valid unless countersigned by our authorized agent or representative.
Countersigned by............................................................................
Authorized Representative
Page of
CONTINUATION OF AMENDED DECLARATIONS FOR PERSONAL AUTO POLICY NO.
NAMED INSURED
3 3
10
99041023BX
ALAN W. ROBERTSON AND
MARLA K. ROBERTSON
Form and Endorsements made part of this policy:
SPECIAL DISCOUNTS
PASSIVE RESTRAINT DISCOUNT AUTOS 1,2
ANTI-THEFT DEVICE DISCOUNT AUTOS 1,2
FWD COLLISION WARNING SYS DISC AUTOS 1,2
ADAPTIVE HEADLIGHTS DISCOUNT AUTOS 1,2
MULTI-LINE DISCOUNT-LIFE
HOMEOWNERSHIP DISCOUNT
ELEC STABILITY CONTROL DISCOUNT AUTOS 1,2
MULTI-CAR DISCOUNT
LOYALTY DISCOUNT
PAID IN FULL DISCOUNT
E-DISCOUNT
AUTOPAY DISCOUNT
PP 00 01 01 05 PERSONAL AUTO POLICY
AM 00 57 10 05 LOSS PAYABLE CLAUSE
PP 13 06 01 09 CUSTOM EQUIPMENT EXCLUSION ENDORSEMENT
PP 23 16 10 13 PERSONAL VEHICLE SHARING PROGRAM EXCLUSION ENDORSEMENT
PP 01 57 01 05 AMENDMENT OF POLICY PROVISIONS - GEORGIA
AM 00 28 11 10 AMENDMENT OF PERSONAL AUTO POLICY PROVISIONS
PP 03 09 01 05 SINGLE LIABILITY LIMIT
PP 04 58 01 05 SINGLE UNINSURED MOTORISTS LIMIT - GEORGIA
PP 04 54 10 15 UNINSURED MOTORISTS - ADDED ON TO AT-FAULT LIAB LIMITS COV - GA
PP 23 40 10 15 PUBLIC OR LIVERY CONVEYANCE EXCLUSION ENDORSEMENT
AM 00 56 10 05 ADDITIONAL INSURED - LESSOR