**** REPRINTED FROM THE ARCHIVE.
THE ORIGINAL TRANSACTION MAY INCLUDE ADDITIONAL FORMS ****
QUANTUM ASSURANCE INT’L INC
513 PRINCE EDWARD ST STE 100 May 2, 2022
FREDERICKSBRG VA 22401-5742
Policy Number: F3764040
24-Hour Claims: 1-800-332-3226
Policy Service: (855) 939-0055
Online Account Services: www.safeco.com
THIS IS NOT A BILL.
WILLIAM BLIZZARD
1212 OWENS DR
MYRTLE BEACH SC 29577-5550
Thank you for allowing us to continue serving your insurance needs.
To ensure you are receiving the best coverage and value available, the following changes have
been made to your 6-month automobile policy, including those requested by you or your agent or
broker.
Your discounts or surcharges have changed. Please read the enclosed policy declarations
page carefully.
This change is effective April 30, 2022. Please place this letter with your insurance policy.
Information on coverages and limits can be found on the revised Declarations page, enclosed.
The credit for this change is $17.59. The billing for this amount will be explained on your next
billing statement.
If you have any questions or wish to make any changes to your policy, you can do so by calling
your agent at (855) 939-0055.
We appreciate the opportunity to serve you. Thank you.
FIRST NATIONAL INSURANCE COMPANY OF AMERICA
OC-429/EP 10/13
**** REPRINTED FROM THE ARCHIVE. THE ORIGINAL TRANSACTION MAY INCLUDE ADDITIONAL FORMS ****
POLICY NUMBER: F3764040
AUTOMOBILE POLICY DECLARATIONS
NAMED INSURED: POLICY CHANGE
WILLIAM BLIZZARD CHANGED EFFECTIVE: APR. 30 2022
1212 OWENS DR POLICY PERIOD FROM: APR. 1 2022
MYRTLE BEACH SC 29577-5550
TO: OCT. 1 2022
at 12:01 A.M. standard time at
the address of the insured as
AGENT: stated herein.
QUANTUM ASSURANCE INT’L INC AGENT TELEPHONE:
513 PRINCE EDWARD ST STE 100 (855) 939-0055
FREDERICKSBRG VA 22401-5742
RATED DRIVERS WILLIAM BLIZZARD
1994 GMC CUTAWAY VAN G3500 2 DOOR ID# 1GDHG31K0RF528112
Insurance is afforded only for the coverages for which limits of liability or
premium charges are indicated.
COVERAGES 1994 GMC LIMITS PREMIUMS
LIABILITY:
BODILY INJURY $25,000 $ 153.30
Each Person
$50,000
Each Occurrence
PROPERTY DAMAGE $25,000 61.90
Each Occurrence
UNINSURED MOTORISTS:
BODILY INJURY $25,000 8.80
Each Person
$50,000
Each Accident
PROPERTY DAMAGE $25,000 1.90
Each Accident
Less $200 Deductible
UNDERINSURED MOTORISTS:
BODILY INJURY $25,000 16.50
Each Person
$50,000
Each Accident
PROPERTY DAMAGE $25,000 1.30
Each Accident
Less $200 Deductible
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TOTAL $ 243.70
PREMIUM SUMMARY PREMIUM
VEHICLE COVERAGES 243.70 $
DISCOUNTS & SAFECO SAFETY REWARDS You saved $147.40 Included
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TOTAL 6 MONTH PREMIUM ................................................... $ 243.70
You may pay your premium in full or in installments. There is no installment fee
for the following billing plans: Full Pay. Installment fees for all other billing
plans are listed below. If more than one policy is billed on the installment bill,
only the highest fee is charged. The fee is:
$2.00 per installment for recurring automatic deduction (EFT)
$5.00 per installment for recurring credit card or debit card
$5.00 per installment for all other payment methods
-CONTINUED-
1-800-332-3226
SA-1697/EP 6/20 Page 1 of 2 DATE PREPARED: MAY 2 2022
**** REPRINTED FROM THE ARCHIVE. THE ORIGINAL TRANSACTION MAY INCLUDE ADDITIONAL FORMS ****
POLICY NUMBER: F3764040
AUTOMOBILE POLICY DECLARATIONS
(CONTINUED)
YOU SAVED $147.40 BY QUALIFYING FOR THE FOLLOWING DISCOUNTS:
Low Mileage
Accident Free
Violation Free
RightTrack (R)
Preferred Payment Method
Policy underwritten by FIRST NATIONAL INSURANCE COMPANY OF AMERICA
(a stock insurance company).
Administrative office: 175 Berkeley St., Boston, MA 02116
Mailing Address: PO Box 704000, Salt Lake City, UT 84170-4000
SA-1698/EP 6/20 Page 2 of 2
