United Automobile Insurance Company

United Group Underwriters ®

P.O. Box 694140
Miami, FL 33269-1140
Phone(305) 940-5022 or (800) 551-2110
WWW.UAIC.COM
Named Insured Information Agent Information
ADOLFO J DIAZ PALACIOS SEBANDA INS FRANCHISE #5
12960 SW 17TH ST 8420 W FLAGLER ST, STE 218A
MIAMI, FL 33175-1217 MIAMI, FL 33144
ORIGINAL POLICY DECLARATIONS
SEMI-ANNUAL FLORIDA PERSONAL AUTO POLICY
Processed Date: 11/30/2021
Policy Number: UAD 000936415 Policy Period:11/30/2021 5:34 P.M. to 05/30/2022 12:01 A.M.
Agent Number: 001-1-100185 Client ID: 000007093743 Previous Policy Number:
This declaration page with ''policy provisions'' and all other applicable
endorsements complete your policy.
DRIVER NAME TYPE OF DRIVER DRIVER CLASS FR
1 ADOLFO JOSE DIAZ PALACIOS Principal 24MS N
DESCRIPTION OF VEHICLE
UNIT YEAR MAKE/MODEL VEHICLE ID # SYMBOL TERRITORY POINTS
1 2018 HYUN ELANTRA KMHH35LEXJU064325 27/34 33S 3
DISCOUNTS
UNIT 1-Air Bag Disc UNIT 1-Anti Lock Brake Disc Paperless Disc
All cars on this policy are garaged at the following address:
12960 SW 17TH ST , MIAMI FL 33175-1217
Coverage is provided only where a premium and limit or deductible are shown:
UNIT 1
COVERAGE LIMIT PREMIUM DED.
Property Damage Liability (PD) 10,000/accident 265.00
Personal Injury Protection[NIO/WLE] 10,000/person 778.00 1,000
Comprehensive MAX ACV 65,000 138.00 1,000
Collision MAX ACV 65,000 824.00 1,000
--------
FULL TERM PREMIUM 2005.00
POLICY FEE 25.00 SETUP FEE 10.00 TOTAL CHARGES 2048.35
MVR FEE 8.35
ENDORSEMENT MADE PART OF THIS POLICY AT TIME OF ISSUE:
APPLICATION APPLICATION
END PTG (2/16) POLICY ENDORSEMENT (02/16)
FL PPA FSN0113 PIP FEE SCHEDULE NOTICE 1/13
POL END(01/13) Policy Endorsement 1/13
POL END(07/15) POLICY ENDORSEMENT PARTD 7/15
UAIC LPC 08/16 LOSS PAYABLE CLAUSE
UAIC 200(7/11) POLICY JACKET
[UNIT# LOSS PAYEE(S) TYPE, NAME, ADDRESS, CITY, STATE AND ZIP CODE]
1 LIENHOLDER, MERFICAP LLC, 2000 PONCE DE LEON BLVD CORAL GABLES FL 33134-4422

Your policy is available online at mypolicy.uaig.net . It is your right to receive a paper copy of your policy at no charge if preferred.
Please call (800) 551-2110 and select the underwriting department to request a paper copy

COUNTERSIGNED: DATE 11/30/2021 By:_______________________________

Form # UAIC FL DEC NB (08/16) Page 1 of 1
Form Name PPA Policy Declarations NB
 (NAIC CODE - 35319) (NAIC CODE - 35319)

UAD 000936415 / 01985 11/30/2021 UAD 000936415 / 01985 11/30/2021

X X
ADOLFO JOSE DIAZ PALACIOS ADOLFO JOSE DIAZ PALACIOS

2018 HYUN ELANTRA KMHH35LEXJU064325 2018 HYUN ELANTRA KMHH35LEXJU064325

NOT VALID AFTER 05/29/2022 NOT VALID AFTER 05/29/2022

 P.O. Box 694140 Miami, FL 33269-1140
PHONE (800) 551-2110

11/30/2021 17:34:03
ADOLFO JOSE DIAZ PALACIOS
12960 SW 17TH ST
UAD -936415
MIAMI, FL 33175-1217

100185
SEBANDA INS FRANCHISE #5
8420 W FLAGLER ST, STE 218A
100185 MIAMI, FL 33144
PHONE# (786)532-1403
NEW BUSINESS

384.20

UAC108958144

0.00

0.00

384.20

0.00

384.20

Form #: UAIC FL Receipt (07/21)

Form Name: Receipt of Payment
United Group Underwriters ®
P.O. Box 694140
Miami, FL 33269-1140 Phone: (305) 940-5022
WWW.UAIG.NET

ADOLFO J DIAZ PALACIOS AGENT CODE: 001-1-100185

12960 SW 17TH ST SEBANDA INS FRANCHISE #5
MIAMI, FL 33175-1217 8420 W FLAGLER ST, STE 2
MIAMI, FL 33144

UAD 000936415 11/30/2021 to 05/30/2022 11/30/2021

5921

12/25/2021 347.94
01/25/2022 347.94
02/25/2022 347.94
03/25/2022 347.94
04/25/2022 348.00