Magallanes Broker Agreement

STANDARD BROKER FEE DISCLOSURE
This disclosure was prepared by the California Insurance Commissioner. Please READ IT
CAREFULLY!
I.
Do not sign any broker fee agreement unless all of its blank lines and spaces have been filled-in and
you have read the entire document and the agreement carefully.
II.
Your insurance broker represents you, the consumer, and is entitled to charge a broker fee if he/she
chooses. This fee is not set by law, and may be negotiable between you and the broker.
III.
It is illegal for an insurance broker to charge you a fee for placing coverage solely with the California
Automobile Assigned Risk Plan or the California Fair Plan. Fees may be charged for placement of
other overages.
IV. Broker fees are often non-refundable even if you cancel your coverage. Refer to your broker fee
agreement to see if your broker fee is non-refundable. However, you may be entitled to a full refund of
a broker fee if your broker acted incompetently or dishonestly. Unresolved disputes over nonrefundable broker fees can be forwarded to the Department of Insurance for review.
V.
You are entitled to obtain and keep a completed copy of this disclosure and any broker fee agreement
you sign.
VI. Your broker may receive a commission from insurance company (ies) for placing your insurance. this
commission may be paid to your broker by the insurance company (ies) in addition to any broker fee
you pay.
VII. If you will be paying your premium in installments to a finance company, by law you must receive a
copy of a premium finance disclosure and agreement. Be sure to obtain and read those documents
before signing a premium finance agreement. Also, ask the broker if the insurer offers its own
installment payment plan. Insurer installment plans are often cheaper than premium financing through a
separate premium finance company.
VIII. If your broker is placing automobile coverage, your broker must provide you with a copy of the current
Department of Insurance pamphlet Automobile Insurance. If your broker is placing residential
coverage, your broker must provide you with a copy of the current Department of Insurance pamphlet
Residential Insurance. By signing this disclosure, you acknowledge receipt of the appropriate
pamphlet(s).
jm
Client Initials: ____________
jm
$50
EARN
IN CASH OR CREDIT TOWARD YOUR MONTHLY PAYMENT
WHEN YOU REFER A FRIEND OR FAMILY MEMBER. JUST MENTION
COUPON CODE # 50REF AND YOUR NAME
Cash reward apply for new Policy only. Other restrictions apply.
NEW MILLENNIUM INSURANCE 714-530-1234
STANDARD BROKER FEE AGREEMENT
jason
magallanes
1. The parties to this agreement are _________________________________("CLIENT")
and New
jason magallanes (May 18, 2015)
Millennium Insurance, California Department of Insurance License # 0H00446 (BROKER)
2. CLIENT appoints BROKER as CLIENT'S insurance broker of record.
3. This agreement shall become operative on ____05-18-15______ (date), and shall continue in full force
until terminated by either party.
4. BROKER agrees to represent CLIENT honestly and competently.
5. CLIENT agrees to pay BROKER a broker fee for BROKER'S services. The broker fee
IS /
IS NOT refundable (circle one).
Broker Fee
Down Payment
Down Given
INCL104
$189.51
$189.51
Remainder Due
Due Date
6. BROKER may in the future charge CLIENT, and CLIENT agrees to pay additional fee(s) for the
services listed below. The additional fees and services are:
Services
Fees
Rewrite or Renew policy within 30 days of cancellation
$100.00
Adding Another vehicle and/or driver to policy
$75.00
Taking and/or making your insurance payment
$10.00
7. Following are the nature and amount of all fees known to BROKER that will be charged by persons
other than BROKER or the insurance company in connection with current placement of CLIENTs
insurance. These fees are not retained by BROKER.
jason magallanes

Client Signature _____________________________________________
Date ___05-18-15____
Broker Signature____BRIAN TOYOTA__________________________ Date ___05-18-15____
In case of any questions or problems concerning broker fees or insurance, contact the Department of
Insurance at 1-(800) 927-HELP.
CREDIT CARD AUTHORIZATION
jason magallanes
I, _________________________________,
authorize New Millennium Insurance, Inc. to charge the
outstanding balance to my credit card account. I also agree that I will not initiate any dispute on this charge in
the future. Only for the amount of _$189.51_
CREDIT / DEBIT CARD NUMBER: __4833160076543500

EXPIRATION DATE: __01/18 372__
jason
magallanes
NAME ( AS IT APPEARS ON CARD ): _________________________________________
SIGNATURE REQUIRED: ______________________________________________
jason magallanes
POWER OF ATTORNEY
I, _____________________________________, ( Client ) grant New Millennium Insurance Inc. permission

to sign all forms on my behalf of client for new policies, renewal policies and endorsement.
This power of Attorney is to remain in full force and effect until revocation in writing is duly given by me,
_______________________, ( Client) and received by New Millennium Insurance Inc.
Signature __________________________
Date ______________________________
ONB
License No: 0C17987
Alliance United Insurance Services

Payment Receipt
Policy #
MNS3348370
Receipt Date
05/18/2015 12:05 PM PT
Insured
JASON ANSURIO MAGALLANESSANCHEZ

1000 ELM AVE
SEASIDE, CA 93955-4906
Confirmation Code
AU3 CRC705J1812558Z
Broker
L & K Millennium Insurance Inc

12801 Harbor Blvd Suite H-5
GARDEN GROVE, CA 92840
(714) 530-1234 Bus
(714) 741-0676 Fax
Amount
$85.51
Please keep this receipt for your records.

Thank You!
NB Application
MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

AU APP 07/08 Copyright
Page 1 of 10
Alliance United Insurance Company
*124*
MNS3348370
License No: 0C17987
RECORD MAINTENANCE AMENDMENT - FILE DOCUMENTS
INSURED NAME:
POLICY #:
MNS3348370
BROKER CODE:
13018
DATE:
5/18/2015 12:05 PM PT
BROKER NAME:
The documents listed in this form must remain in the policyholders file and be maintained by your brokerage for a minimum of five (5) years
from the expiration/cancellation date of this policy.
Please place this form in the file and confirm the documents are included by checking the appropriate box. It is the responsibility of the
producing broker to complete this form and maintain all records in accordance with the Alliance United Record Maintenance Amendment.
A fully and completed signed application including Uninsured Motorist Waiver

Copy of MVRs for all listed drivers (unless Alliance United's on-line MVR is used when bridging the application)
Copies of Drivers license or I.D. for all drivers domestic or foreign.
Copies of the current registration or sales contract (new or used vehicles) for all vehicles.
Photos
l
l
Brokers are responsible for taking two photos showing all sides of the vehicle. The photos must be retained with the application.
Will be waived for new and used vehicles that are purchased or leased from a dealer within the last 30 days. A copy of the
sales contract for each vehicle must accompany the application.
Will be waived if a copy of the prior policy is in the file showing Physical Damage coverage for the vehicle(s) with no lapse in
coverage.
Will be required and retained for all vehicles rated as artisan regardless of coverages.
Proof of No-Fault or No-Bodily Injury Accident (if applicable).

Signed Driver Exclusion (If applicable).
Registered Owners are listed as a driver or excluded.
Copy of the FSC or other rating service quote.
Proof of Marriage / Proof of identification of an excluded spouse / domestic partner
Proof of identification will be required for the excluded spouse when the system asks for proof at time of upload. We will
require proof the excluded spouse exists and resides with the insured if the registration or other file documents show both
names. Examples of proof are: a photo ID, a bill in the excluded persons name showing the same address as the insured,
a marriage certificate or tax return.
Marriage rates apply to domestic partners living in the same household. Domestic Partnership Affidavit is acceptable only
for same sex partners. Same requirements for proof as above.
THIS COVER PAGE, APPLICATION AND REQUIRED BACKUP ARE FOR ELECTRONIC PURPOSES ONLY.
**** IMPORTANT NOTICE ****
ANY REQUESTS FOR CHANGES, MODIFICATIONS OR AMENDMENTS MUST BE SUBMITTED TO ALLIANCE UNITED SEPARATELY BY
FAX (866) 530-2500 OR E-MAILED TO policyservices@allianceunited.com IN ORDER TO BE ACKNOWLEDGED FOR PROCESSING
AND BINDING OF COVERAGE.

Page 2 of 10
*124*
MNS3348370
NAIC No.
Broker
Policy #
10920
13018
MNS3348370
Broker Name and Address

12801 Harbor Blvd Suite H-5
GARDEN GROVE, CA 92840
(714) 530-1234
Program Name
Millennium
Applicant Information
Named Insured Mailing Address
Effective Date & Time

05/18/2015 12:05 PM PT

1000 ELM AVE
SEASIDE,CA 93955-4906
Expiration Date & Time

6/18/2015 12:01 AM PT
Payment Plan
Full Pay
E-mail Address
JSEASIDE831@GMAIL.COM
Home Phone
(831) 383-2161
Garaging Address (If Different)
Same As Mailing Address
All residents of your household who are 14 years of age and older and any person who regularly drives listed vehicles must be listed as a driver or
excluded.
Driver Information - Name of all drivers (licensed or permitted) in household
Name
Applicant
Gender
7/11/1996
Self
JASON ANSURIO
MAGALLANESSANCHEZ
Date of
Birth
Marital
Status
Lic #
State
Date
Licensed
SR
F7987354
CA
7/11/2012
Accidents and Convictions within the past 36 months

Driver #
Date
Description
10/31/2014
DUI ALCOHOL AND/OR DRUGS (23152A) 1 pts
10/31/2014
SUSPENSION (SUSP) 0 pts
05/18/2015
REINSTATEMENT (REIN) 0 pts
11/24/2014
05/18/2015
01/27/2015
05/18/2015
05/18/2015
Not A Valid License (01AU) 0 pts

Vehicle Information
Year
Make
Model
1996
JEEP
GRAND CHER
LAREDO
VIN
1J4GZ58Y7TC327925

Page 3 of 10
Annual
Mileage
8500
*124*
Use
Pleasure
Symbol
Purchase
Date
T-16-16
MNS3348370
New/Used
Used
Coverage Information - Coverage does not apply unless a premium is indicated

Veh# 1
Limit
Prem
Liability - Bodily Injury
15/30
$29.03
Liability - Property
Damage
5,000
$31.34
Total
$60.37
Total Policy Premium
$60.37
Total Anti-Fraud Fee
$0.14
SR Filling Fee
$5.00
Policy Fee
$20.00
Total Policy Premium
$85.51
Down Payment
$85.51
Additional Comments
5/18/2015 12:05:06
PM
- New business policy was auto-released via OIS.

-- FSC Quoted Premium : 98.61 User Name : 13018
Alliance United Company offers multiple California Personal Auto Programs to eligible insured's. A lower rate or better coverage may be
available to you. If you would like more information about these programs or to obtain a quote, please contact your broker at (714) 530-1234.

Page 4 of 10
*124*
MNS3348370
REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE
The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance policy it
issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also permit the insurer and the
applicant to (1) delete the coverage completely or, (2) to delete the coverage when a motor vehicle is operated by a natural person or persons
designated by name or, (3) agree to provide the coverage in an amount less than that required by subdivision (m) of section 11580.2 of the
Insurance Code but not less than the financial responsibility requirements. Uninsured motorist coverage insures the insured, his or her heirs, or
legal representatives for all sums within the limits established by law, which the person or persons are legally entitled to recover as damages for
bodily injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an uninsured motor vehicle not
owned or operated by the insured or a resident of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as
defined in subdivision (p) of section 11580.2 of the Insurance Code.
This to certify that I understand I have been offered Uninsured Motorist Bodily Injury coverage limits equal to my Bodily Injury coverage limits.
I REJECT Uninsured Motorist coverage in its entirety.
I elect to delete Uninsured Motorist coverage for Property Damage, but keep Uninsured Motorist coverage for Bodily Injury.
I DO NOT wish to carry Uninsured Motorist Bodily Injury limits equal to my Liability Bodily Injury coverage limits. The reduced limits
of Uninsured Motorist Bodily Injury coverage I request are:
$15,000/$30,000
(initial)
$25,000/$50,000
(initial)
$30,000/$60,000
(initial)
jason magallanes
jason magallanes (May

18, 2015)
Signature
May 18, 2015
of Named Insured

Page 5 of 10
Date
*124*
MNS3348370
MILLENNIUM APPLICATION DISCLOSURES

BUSINESS USE EXCLUSION
It is agreed that the insurance afforded by this policy does not apply while any motor vehicle listed in the policy is used in the course of
the insureds business.
Initials:
jm
jm
DISCLOSURE OF HOUSEHOLD MEMBERS AND OTHER DRIVERS

I have listed all residents of my household 14 years old and older and any person(s) who regularly drive listed vehicles on this policy
or excluded them from coverage. I agree to notify the Company of any changes in listed operators. I understand that my failure to notify
the Company of any resident(s) of my household or any person(s) who regularly operate a vehicle shall be considered to be a
misrepresentation and may render my policy null and void.
Initials:
jm
jm
Disclosure of Registered Owners and Insurable Interest

I acknowledge and understand that all registered owners and any person with an insurable interest of all vehicles listed on the policy
must be rated as drivers or excluded from the policy. In addition, all registered owners must be listed as additional interest for any
vehicle that has comprehensive and collision coverage.
Failure to add the registered owner as an additional interest may result in
comprehensive and collision coverage being denied in case of a claim. I agree to notify the Company of any changes in registered
owners. I understand that my failure to notify the Company shall be considered to be a misrepresentation and may render my policy
null and void.
Initials:
jm
jm
ANNUAL MILEAGE STATEMENT

I acknowledge that the estimated annual vehicle
knowledge. I understand that the Company may
annual vehicle mileage I have provided. If a loss
premium from any loss settlement. I understand
renewal.
mileage I have provided on this application is true and correct to the best of my
retroactively adjust my premium if the actual miles driven differ from the estimated
occurs under this policy the Company shall have the option to deduct such additional
that the Company may request that estimated annual mileage be updated at policy
Initials:
jm
jm
STATEMENT OF VEHICLES OWNED (IF SR FILING REQUIRED)

All of the vehicles owned by myself (or my spouse) are insured on the above referenced policy. I understand that it is my responsibility to
add coverage to the policy for any vehicle(s) acquired by me (or my spouse) during the policy term.
Initials: jm
jm

Page 6 of 10
*124*
MNS3348370
Notice of Information Practices
I understand that in connection with my request for a premium quotation and application for insurance (1) the insurance company
may obtain consumer reports, which may include a driver history report or vehicle report and I grant them the authority to do so. I
agree that the insurance company may correct my premium if the information obtained from additional sources, including motor
vehicle reports, changes factors which affect the premium; (2) in certain circumstances such information, as well as other personal
privileged information subsequently collected by the insurance company, may be disclosed to third parties without my permission;
(3) upon my written request, within a reasonable time period, the insurance company will inform me whether or not a consumer
report was requested and the name and address of the consumer reporting agency that furnished the report; (4) the insurance
company may request and utilize the subsequent consumer reports in connection with updating and renewing any insurance
afforded in connection with this application; (5) refusal to authorize the insurance company to obtain a consumer report may give the
insurance company the right to decline personal or family insurance to me.
I understand that the coverage selection and limit choices indicated here or in any state supplement will apply to all future policy
renewals, continuations, and changes unless I notify you otherwise in writing.
Applicant's Statement
I have read the above application and any attachments. I declare that the information provided in them is true, complete, and correct
to the best of my knowledge and belief. This information is being offered to the company as an inducement to issue the policy for
which I am applying.
I understand that this policy was issued in reliance upon the information provided on this application for
insurance. I agree that the facts and information contained in this insurance application are correct and accurate and that I have not
failed to disclose any material facts relating to the risks insured under this policy.
I understand that Alliance United Insurance
Company may void this policy and/or deny coverage for an accident or loss if I, or an insured person, has concealed or
misrepresented any material fact or circumstance, or engaged in fraudulent conduct, at the time this application is made or at any
time during the policy period. The insurance company may void this policy for fraud or misrepresentation even after the occurrence
of an accident or loss.
I further declare that I have not had an accident or theft loss in the last 72 hours.
for accidents occurring in Mexico.
I further understand that coverage does not extend
I am aware that pursuant to California Insurance Code Section 1879.2, any person who knowingly presents a false
claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. In
person who knowingly makes an application for motor vehicle insurance coverage containing any statement that
resides or is domiciled in this state when, in fact, that applicant resides or is domiciled in a state other than this state,
criminal and civil penalties.
jason magallanes
or fraudulent
addition, any
the applicant
is subject to
May 18, 2015
Signature of Named Insured
Date
The broker warrants that the policy provisions and exclusions have been explained to the applicant.
Broker Signature

Page 7 of 10
Date
*124*
MNS3348370
CALIFORNIA INSURANCE PROOF CERTIFICATE

Department of Motor Vehicles
P.O. Box 932338
Sacramento, CA 94232-338
The company named below, which is authorized to do business in the State of California, certifies that it has issued to or for the benefit of:
(Please Print or Type)
NAME
DRIVER LICENSE NO.
DATE OF BIRTH
F7987354
7/11/1996
ADDRESS
CITY
STATE
ZIP
1000 ELM AVE
SEASIDE
CA
93955-4906
POLICY NO.
EFFECTIVE DATE
TIME SUBMITTED
MNS3348370
05/18/2015
12:05 pm
ASSIGNED RISK PLAN NO.
CHECK ONE BOX ONLY:

SR-1P
SR-22
(P)
An automobile liability policy as defined in California Vehicle Code Section 16054.
(M)
Any other liability policy as defined in California Vehicle Code Section 6431 which meets the requirements of
Section 16056 for vehicles with less than four wheels.
(S)
A motor vehicle liability policy as defined in California Vehicle Code Section 16450. (BROAD COVERAGE)
(U)
Owners policy covering all motor vehicles registered to the insured. (Section 16451)
(T)
Operators policy covering the use by the insured of any motor vehicle not registered to the insured. (Section 16452)
Cancellation or termination of this policy shall be in accordance with Vehicle Code Section 16433.
NAME OF INSURANCE COMPANY
DEPT. OF INSURANCE I.D. NO.
ALLIANCE UNITED INSURANCE COMPANY
4532
ADDRESS OF INSURANCE COMPANY
5300 ADOLFO ROAD STE 200

CITY
STATE
ZIP
CAMARILLO
CALIFORNIA
93012
AUTHORIZED REPRESENTATIVE
DATE
05/18/2015
SR-22/SR-1P (REV. 1/97)
STATE COPY

Page 8 of 10
*124*
MNS3348370
CALIFORNIA INSURANCE PROOF CERTIFICATE

Department of Motor Vehicles
P.O. Box 932338
Sacramento, CA 94232-338
The company named below, which is authorized to do business in the State of California, certifies that it has issued to or for the benefit of:
(Please Print or Type)
NAME
DRIVER LICENSE NO.
DATE OF BIRTH
F7987354
7/11/1996
ADDRESS
CITY
STATE
ZIP
1000 ELM AVE
SEASIDE
CA
93955-4906
POLICY NO.
EFFECTIVE DATE
TIME SUBMITTED
MNS3348370
05/18/2015
12:05 pm
ASSIGNED RISK PLAN NO.
CHECK ONE BOX ONLY:

SR-1P
SR-22
(P)
An automobile liability policy as defined in California Vehicle Code Section 16054.
(M)
Any other liability policy as defined in California Vehicle Code Section 6431 which meets the requirements of
Section 16056 for vehicles with less than four wheels.
(S)
A motor vehicle liability policy as defined in California Vehicle Code Section 16450. (BROAD COVERAGE)
(U)
Owners policy covering all motor vehicles registered to the insured. (Section 16451)
(T)
Operators policy covering the use by the insured of any motor vehicle not registered to the insured. (Section 16452)
Cancellation or termination of this policy shall be in accordance with Vehicle Code Section 16433.
NAME OF INSURANCE COMPANY
DEPT. OF INSURANCE I.D. NO.
ALLIANCE UNITED INSURANCE COMPANY
4532
ADDRESS OF INSURANCE COMPANY
5300 ADOLFO ROAD STE 200

CITY
STATE
ZIP
CAMARILLO
CALIFORNIA
93012
AUTHORIZED REPRESENTATIVE
DATE
05/18/2015
SR-22/SR-1P (REV. 1/97)
PRODUCER COPY

Page 9 of 10
*124*
MNS3348370
California Insurance ID Card

PO Box 6042
Camarillo, CA 93011-6042
Effective Date
Policy Number
NAIC # 10920
Expiration Date
05/18/2015
MNS3348370
If You Are In An Accident
11/18/2015
1.
Do not leave the scene.
2.
Call the police to report the accident.
3.
Call at (800) 508-5833.
4.
Do not admit fault. Do not discuss the accident with

anyone except the police and your representative.
5.
Exchange information with the other driver. Ask for the

following:
address, driver's license number, and phone
* Name,
numbers of other drivers and witnesses.
(ID card valid only if coverage is in-force)
Named Insured:
Named Drivers:
JASON ANSURIO
MAGALLANESSANCHEZ
1000 ELM AVE
SEASIDE,
CA 93955-4906
- JASON ANSURIO
MAGALLANESSANCHEZ
*
*
Broker:
(714) 530-1234
Vehicle Information
Year
Make
1996
JEEP
Model
GRAND CHER LAREDO
Year, make, model, and license plate number of all

vehicles involved.
Name of Insurance Company and policy number of
other drivers.
VIN #
1J4GZ58Y7TC327925
Signature:
Email: nminsurance2@gmail.com

Page 10 of 10
*124*
MNS3348370

Magallanes Broker Agreement

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Magallanes Broker Agreement

Încărcat de

Drepturi de autor:

Formate disponibile

STANDARD BROKER FEE DISCLOSURE

NEW MILLENNIUM INSURANCE 714-530-1234

STANDARD BROKER FEE AGREEMENT

Rewrite or Renew policy within 30 days of cancellation

Adding Another vehicle and/or driver to policy

Taking and/or making your insurance payment

jason magallanes (May 18, 2015)

Broker Signature____BRIAN TOYOTA__________________________ Date ___05-18-15____

CREDIT CARD AUTHORIZATION

CREDIT / DEBIT CARD NUMBER: __4833160076543500

I, _____________________________________, ( Client ) grant New Millennium Insurance Inc. permission

License No: 0C17987

Alliance United Insurance Services

JASON ANSURIO MAGALLANESSANCHEZ

L & K Millennium Insurance Inc

Please keep this receipt for your records.

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

License No: 0C17987

RECORD MAINTENANCE AMENDMENT - FILE DOCUMENTS

A fully and completed signed application including Uninsured Motorist Waiver

Proof of No-Fault or No-Bodily Injury Accident (if applicable).

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

Broker Name and Address

Effective Date & Time

JASON ANSURIO MAGALLANESSANCHEZ

Expiration Date & Time

Garaging Address (If Different)

Same As Mailing Address

Accidents and Convictions within the past 36 months

DUI ALCOHOL AND/OR DRUGS (23152A) 1 pts

SUSPENSION (SUSP) 0 pts

REINSTATEMENT (REIN) 0 pts

SUSPENSION (SUSP) 0 pts

REINSTATEMENT (REIN) 0 pts

SUSPENSION (SUSP) 0 pts

REINSTATEMENT (REIN) 0 pts

Not A Valid License (01AU) 0 pts

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

Coverage Information - Coverage does not apply unless a premium is indicated

Liability - Bodily Injury

Total Anti-Fraud Fee

Total Policy Premium

- New business policy was auto-released via OIS.

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE

I REJECT Uninsured Motorist coverage in its entirety.

jason magallanes (May

May 18, 2015

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

MILLENNIUM APPLICATION DISCLOSURES

DISCLOSURE OF HOUSEHOLD MEMBERS AND OTHER DRIVERS

Disclosure of Registered Owners and Insurable Interest

ANNUAL MILEAGE STATEMENT

STATEMENT OF VEHICLES OWNED (IF SR FILING REQUIRED)

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

Notice of Information Practices

I further understand that coverage does not extend

May 18, 2015

jason magallanes (May 18, 2015)

Signature of Named Insured

MNS3348370 - JASON ANSURIO MAGALLANESSANCHEZ

CALIFORNIA INSURANCE PROOF CERTIFICATE

DRIVER LICENSE NO.

JASON ANSURIO MAGALLANESSANCHEZ

Broker SignatureBRIAN TOYOTA____________________ Date _05-18-15____