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Personal Auto Declaration: Policy Premium Total $1,314.00

This document is an auto insurance declaration from Security National Insurance Company providing coverage to Albenys Alonso for their 2007 Toyota Yaris. It lists the policy period as December 16, 2021 to June 16, 2022. The total policy premium is $1,314 and includes a $25 MGA fee and $10 underwriting fee. Coverage includes $10,000 personal injury protection with a $1,000 deductible, $10,000 property damage liability with a $503 premium, and additional fees for installment payments, late payments, NSF payments, and paper billing.

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Albenys Alonso
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2K views2 pages

Personal Auto Declaration: Policy Premium Total $1,314.00

This document is an auto insurance declaration from Security National Insurance Company providing coverage to Albenys Alonso for their 2007 Toyota Yaris. It lists the policy period as December 16, 2021 to June 16, 2022. The total policy premium is $1,314 and includes a $25 MGA fee and $10 underwriting fee. Coverage includes $10,000 personal injury protection with a $1,000 deductible, $10,000 property damage liability with a $503 premium, and additional fees for installment payments, late payments, NSF payments, and paper billing.

Uploaded by

Albenys Alonso
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Security National Insurance Company

PERSONAL AUTO DECLARATION


PO BOX 31029 POLICY NUMBER Policy Period
INDEPENDENCE, OH 44131-0029 From To
1-888-888-0080
Inquire or pay your bill online using www.bristolwest.com
G01 1505074 00 12/16/2021 later of 12:01 a.m. or time 06/16/2022 12:01a.m.*
application is executed

*Unless cancelled sooner for valid reasons.


Named Insured: 0901122
ALBENYS A ALONSO D’ALEO INSURANCE LLC
9711 BAYOU BLUFF DR 8759 NW 50TH ST
JACKSONVILLE FL 32257-8976 LAUDERHILL FL 33351-5403
Telephone: 954-931-2900

POLICY PREMIUM TOTAL $1,314.00


(includes $25.00 for MGA Policy fee and a $10.00 Underwriting fee)
Transaction Description
POLICY DECLARATION
Drivers
Drivers on Policy Rated Filing Birth Mar Sex
ALBENYS A ALONSO Rated No 2000 S M
CRISTHEEAMNS A MORALES Excluded No 2004 S M
CRISTHOPHER A MORALES GARRIDO Excluded No 2003 S M
Forms and Endorsements
FLSNPIP02 (12/20) 1005 (02/11) 40155 (11/13) FL-GLL-01 (06/21) 40198 (06/16) FL-PCE-01 (06/18)

Vehicle 1 PREMIUM $1,279.00


Year / Make / Model: 2007 TOYOTA YARIS BASE/YARIS Vehicle Use: Pleasure
Vehicle Identification#: JTDBT923071109820
Discounts: Go Paperless, EFT, Air Bag
Rating Zip Code: 32257
Garaging Location: Same
Loss Payee: N/A
Additional Interest: N/A
Per Person Per Accident Deductible Premium
Coverage Limit Limit
BODILY INJURY LIABILITY Rejected
PROPERTY DAMAGE LIABILITY 10,000 503.00
BASIC PERSONAL INJURY PROTECTION 10,000 1000 776.00
Medical Benefits will be limited to a maximum of $2,500 if there is
no Emergency Medical Condition as defined in our Policy. Under
Personal Injury Protection Coverage, you are also entitled to a
$5,000 Death benefit, which is in excess of the maximum Personal
Injury Protection Limit of $10,000.
DEDUCTIBLE APPLIES TO NAMED INSURED ONLY
WORK LOSS BENEFITS INCLUDED
UNINSURED MOTORIST BODILY INJURY Rejected

49009 (10/19) Authorized Representative


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Additional Fee Information

In addition to the "Fees" identified in the “Policy Premium Total” section above, the following additional fees also apply:

In consideration of our agreement to allow you to pay in installments, the following service fee will apply:
I agree to pay an interest charge equal to (18) percent simple interest per year on the unpaid balance of my policy
capped at $10 per installment that becomes due during the policy term and during each renewal policy term in
accordance with the payment plan.
In addition, the following fees also apply:
LATE FEE: $10.00 (applied per policy term and each renewal policy for any payment that is not postmarked by the
scheduled due date)
NSF/RETURNED PAYMENT CHARGE: $15.00 (applied per each check or draft which is returned for
non-sufficient funds )
PAPER DOCUMENTS FEE: $10.00 (applied per policy when paper documents are sent instead of receiving
electronic documents through our Go Paperless feature)

THIS POLICY DOES NOT PROVIDE BODILY INJURY AND PROPERTY DAMAGE
LIABILITY INSURANCE OR ANY OTHER COVERAGE FOR WHICH A SPECIFIC
PREMIUM CHARGE IS NOT MADE, AND DOES NOT COMPLY WITH ANY
FINANCIAL RESPONSIBILITY LAW.
For accidents occurring outside the state of Florida, see the Coverage Deemed Granted by Out-of-State Statute provisions of your
policy.

49009 (10/19)

Authorized Representative

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