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MAIL MCH-M-I
3B930
AUGUST 12, 2022
AUTOMOBILE POLICY PACKET
OMAR FRANCISCO RIVERA
PO BOX 176
TWIN PEAKS CA 92391-0176
GIC 04066 51 02 7110 6
POLICY PERIOD: EFFECTIVE AUG 13 2022 TO FEB 02 2023
IMPORTANT MESSAGES
Refer to your Declarations Page and endorsements to verify that coverages, limits, deductibles and other
policy details are correct and meet your insurance needs. Required information forms are also enclosed
for your review.
Check your vehicle for a safety recall today! Visit www.usaa.com/autorecall
to learn more.
Your safety matters to USAA. Visit http://usaa.com/autoadvice for our
latest auto insurance and driving safety tips.
This is not a bill. Any premium charge or change for this policy will be reflected on your
next regular monthly statement. Your current billing statement should still be paid by
the due date indicated.
To receive this document and others electronically, or manage your Auto Policy online,
go to usaa.com.
For U.S. calls: Policy Service (800) 531-8111. Claims (800) 531-8222.
ACS1 49708-0406
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USAA GENERAL INDEMNITY COMPANY AMENDMENT TO
(A Stock Insurance Company) State 15 Veh POLICY NUMBER
9800 Fredericksburg - San Antonio, Texas 78288 CA 365 XX
Terr 04066 51 02G 7110 6
CALIFORNIA AUTO POLICY POLICY PERIOD: (12:01 A.M. standard time)
AMENDED DECLARATIONS EFFECTIVE AUG 13 2022 TO FEB 02 2023
(ATTACH TO PREVIOUS POLICY) OPERATORS
Named Insured and Address 01 OMAR FRANCISCO RIVERA
OMAR FRANCISCO RIVERA
PO BOX 176
TWIN PEAKS CA 92391-0176
Description of Vehicle(s) VEH USE* WORK/SCHOOL
Miles Days
VEH YEAR TRADE NAME MODEL BODY TYPE ANNUAL One Per
MILEAGE IDENTIFICATION NUMBER SYM Way Week
15 17 JEEP CHEROKEE 4D 5500 1C4PJMBS2HW618270 P
The Vehicle(s) described herein is principally garaged at the above address unless otherwise stated. * W/C=Work/School; B=Business; F=Farm;P=Pleasure
VEH 15 REDLANDS CA 92374-2181
This policy provides ONLY those coverages where a premium i s shown below. The limits shown
m a y b e reduced b y policy provisions and m a y not b e combined regardless o f the number of
vehicles for which a premium is listed unless specifically authorized elsewhere in this policy.
VEH VEH VEH VEH
COVERAGES LIMITS OF LIABILITY 15 6-MONTH
("ACV" MEANS ACTUAL CASH VALUE) D=DED PREMIUM D = D E D PREMIUM D = D E D PREMIUM D=DED PREMIUM
AMOUNT $ AMOUNT $ AMOUNT $ AMOUNT $
PART A - LIABILITY
BODILY INJURY EA PER $ 100,000
EA ACC $ 300,000 132.79
PROPERTY DAMAGE EA ACC $ 100,000 119.87
PART B - MEDICAL PAYMENTS
EA PER $ 10,000 16.24
EXTENDED BENEFITS
WAGE EARNER DISAB $2,000 PER 30-DAY PERIOD
ESSENTIAL SVCS DISAB $45 WK 5.28
PART C - UNINSURED MOTORISTS
BODILY INJURY EA PER $ 100,000
EA ACC $ 300,000 47.10
PART D - PHYSICAL DAMAGE COVERAGE
COMPREHENSIVE LOSS ACV LESS D 250 52.91
COLLISION LOSS ACV LESS D 250 328.22
RENTAL REIMBURSEMENT
MULTIPASSENGER/TRUCK CLASS 36.00
TOWING AND LABOR 8.24
TOTAL PREMIUM - SEE FOLLOWING PAGE(S)
LOSS PAYEE
VEH 15 ARROWHEAD CREDIT UNION, CRESTLINE CA
ENDORSEMENTS: ADDED 08-13-22 - NONE
REMAIN IN EFFECT(REFER TO PREVIOUS POLICY)- RSGPCW(01) 5100CA(02)
V V V V
E
H
15 RSM57000N E
H
E
H
E
H
IN WITNESS WHEREOF, we have caused this policy to be signed by our President and Secretary at San Antonio, Texas,
on this date AUGUST 12, 2022
5000 G 0 5 - 1 2
53384- 05-12
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USAA GENERAL INDEMNITY COMPANY AMENDMENT TO
(A Stock Insurance Company) State Veh POLICY NUMBER
9800 Fredericksburg - San Antonio, Texas 78288 CA XX
Terr 04066 51 02G 7110 6
CALIFORNIA AUTO POLICY POLICY PERIOD: (12:01 A.M. standard time)
AMENDED DECLARATIONS EFFECTIVE AUG 13 2022 TO FEB 02 2023
(ATTACH TO PREVIOUS POLICY)
Named Insured and Address
OMAR FRANCISCO RIVERA
PO BOX 176
TWIN PEAKS CA 92391-0176
Description of Vehicle(s) VEH USE* WORK/SCHOOL
Miles Days
ANNUAL One Per
VEH YEAR TRADE NAME MODEL BODY TYPE MILEAGE IDENTIFICATION NUMBER SYM Way Week
The Vehicle(s) described herein is principally garaged at the above address unless otherwise stated. * W/C=Work/School; B=Business; F=Farm;P=Pleasure
This policy provides ONLY those coverages where a premium i s shown below. The limits shown
m a y b e reduced b y policy provisions and m a y not b e combined regardless o f the number of
vehicles for which a premium is listed unless specifically authorized elsewhere in this policy.
VEH VEH VEH VEH
COVERAGES LIMITS OF LIABILITY
("ACV" MEANS ACTUAL CASH VALUE) D=DED PREMIUM D = D E D PREMIUM D = D E D PREMIUM D=DED PREMIUM
AMOUNT $ AMOUNT $ AMOUNT $ AMOUNT $
___________________________________________________________________________________
VEHICLE TOTAL PREMIUM 746.65
-------------------------------ADJUSTMENT REASON--------------------------------
CHANGE IN ANNUAL MILEAGE VEH 15
REVISED 6 MONTH PREMIUM...$ 746.65 6 MONTH DECREASE...$ 63.96
PREMIUM DUE AT INCEPTION. THIS IS NOT A BILL, STATEMENT TO FOLLOW.
V V V V
E E E E
H H H H
In WITNESS WHEREOF, we have caused this policy to be signed by our President and Secretary at San Antonio, Texas,
on this date AUGUST 12, 2022
5000 G 0 5 - 1 2
53384- 05-12
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GIC 04066 51 02 7110
SUPPLEMENTAL INFORMATION
EFFECTIVE AUG 13 2022 TO FEB 02 2023
The following approximate premium discounts or credits have already been applied to reduce your policy
premium costs.
NOTE: Age or senior citizen status, if allowed by your state/location, was taken into consideration when
your rates were set and your premiums have already been adjusted.
VEHICLE 15
ANNUAL MILEAGE DISCOUNT -$ 156.53
DEFENSIVE DRIVING DISCOUNT: -$ 15.29
MATURE DRIVER IMPROVEMENT COURSE
OPERATOR 01 -- (CERTIFICATE EXPIRES 07-30-25)
GOOD DRIVER DISCOUNT -$ 186.66
OPERATOR 01
MULTI-POLICY DISCOUNT -$ 61.27
RENTERS, ALL OTHER PROPERTY AND CASUALTY LINES
PASSIVE RESTRAINT DISCOUNT -$ 2.66
PREMIER OPERATOR DISCOUNT -$ 204.77
SUPDECCW Rev. 7-95 AUGUST 12, 2022
