CSAA Insurance Exchange
PO Box 24523
Oakland, CA 94623-1523
YOUR CLAIM INFORMATION
ANTWAN DAVIS Claim number 1005-78-2354
169 HAP ARNOLD LOOP B
UNIT B Policy number CAH4231683085
ROSEVILLE, CA 95747 Policyholder Antwan Davis
Date of incident June 18, 2024
Fallon McCormack
June 19, 2024 888.335.2722, Ext. 1201789
Regular Claims Center hours are
Monday - Friday 8:00 AM - 6:00 PM,
Dear Antwan Davis: Eastern Time
Thank you for choosing AAA and trusting us with your insurance needs.
We are writing to you to confirm that a claim has been opened on your policy.
At AAA, we strive to make your claims experience as easy and smooth as possible. We’ll work with you throughout the
process, provide fast, caring service and resolve your claim fairly.
Please review all of the enclosed documents and take note of any additional information we need from you.
We value you as our customer and appreciate the opportunity to assist you.
Sincerely,
Fallon McCormack
Fallon McCormack
Claims Representative
For your protection California law requires the following to appear on this form: “Any person who knowingly presents false
or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of
a crime and may be subject to fines and confinement in state prison.”
Please turn the page and on the back you’ll find the sections listing “What you
need to do” and “What’s inside.”
For questions about your policy, please refer to the policy booklet previously
provided to you. You can request a copy of your policy booklet from your claims
representative.
Page 1 of 6
What you need to do
Complete and sign the Sworn Statement in Proof of
Loss (enclosed)
What's inside
About your deductible Your policy coverage
Loss of use coverage Getting repairs
Making an inventory of your personal items How to submit documents
Other important information More about your loss of use coverage
Insurance Code Section 790.03
Page 2 of 6
CSAA Insurance Exchange
PO Box 24523
Oakland, CA 94623-1523
About your deductible
Glass $50 Deductible
Section I $250 Deductible
Each deductible above is applied once per incident. Depending on the outcome of the investigation, more than one
deductible may apply.
Your policy coverage
Your policy provides the following coverages. Some of these coverages apply to your incident. For more information about
your coverage, please contact us at the phone number listed under Your Claim Information box on page one.
C-Personal Property $15,000 per occurrence
D-Loss of Use $3,000 per occurrence
E-Personal Liability $100,000 per occurrence
F-Medical Payments to Others $1,000 per person/$25,000 per occurrence
Fungi, Wet or Dry Rot or Bacteria $10,000 per policy period
Loss Assessment
Workers Compensation $100,000 per occurrence
Loss of use coverage
Your policy provides coverage for loss of use. Loss of use is when you have to leave your property because it is uninhabitable
as a result of a covered incident, or if a mandatory evacuation is required. There are three types of benefits under loss of use:
1. Additional living expenses – reasonable costs above and beyond your normal cost of living.
2. Fair rental value – the market value of all or part of your property that you normally rent or lease.
3. Mandatory evacuation – up to two weeks of additional living expenses or fair rental value when your property is not
damaged but is threatened by a covered incident.
For further information on loss of use coverage, please see the last page in this letter.
Page 3 of 6
Getting repairs
You have the right to select the contractor of your choice to repair covered damage to your property. At your request, we
will refer you to our Network Repair Program. Depending on your location and type of repair needed, a contractor may be
available to assist you.
All contractors that are part of the Network Repair Program are properly licensed, bonded, and insured. The program
monitors the quality and timeliness of repairs, in addition to providing a workmanship warranty. If you would like a referral
to our Network Repair Program, you can contact us at the phone number listed on page one of this letter.
Making an inventory of your personal items
We will need you to provide an inventory of personal items impacted by this incident. If we have not already secured an
inventory of your impacted items, we will provide a web address to submit an inventory online. If you prefer a paper inventory
form to submit, you can contact us at the phone number listed on page one of this letter.
How to submit documents
Please send all correspondence documents and completed forms as described below, including your claim number on
each document to expedite the processing of your claim.
● Email: claimdocs@csaa.com
Include claim number 1005-78-2354 in the subject line in the exact format to ensure proper delivery.
● Fax: 877.548.1610
Provide a cover sheet and include claim number 1005-78-2354.
● Mail: CSAA Insurance Exchange
PO Box 24523 Oakland CA 94623-1523
Include claim number 1005-78-2354.
AAA only keeps digital copies of submitted documentation relating to your claim. Please do not send us original documents,
as we cannot keep or return them.
Other important information
Burglary or theft
To complete your burglary or theft claim, we need a filed police report listing all stolen or missing items. We can request
a copy of this report, but it may speed up your claim investigation to send us your copy. For delivery options, please refer
to the “How to submit documents” section.
When AAA has paid you for this incident, the stolen and missing items become the property of AAA. Should the items or
property be found or recovered, you are required to notify us.
Protecting your property from further damage
If your loss requires emergency services or temporary repairs, you have the responsibility to take steps to protect the
property from further damage. Please remember to keep an accurate record of all repair expenses. Also, please do not get
rid of anything related to the repairs without checking with us. If you do not protect your property from further damage, you
may not be able to submit a claim for the damage to your dwelling, other structures or personal property insured by AAA.
Your rights
It is important that you be aware of your rights. Following California state law, we have included a copy of the Insurance
Code Section 790.03. In addition to this section of the Insurance Code provided, the Fair Claims Settlement Regulations
also cover how insurance claims must be processed in this state. These regulations are available at the Department of
Insurance Internet site, www.insurance.ca.gov.
We send claim information to one or more claims information databases. The information is used to provide loss
history reports to insurers. If you would like to receive a report from a claims information database, contact ChoicePoint
Consumer Center, PO Box 105108, Atlanta, Georgia 30348-5108, by phone at 1-800-456-6004 (24 hours), or via internet
at www.choicepoint.com.
Page 4 of 6
CSAA Insurance Exchange
PO Box 24523
Oakland, CA 94623-1523
Actions against AAA
No action can be brought against us unless there has been full compliance with the policy provisions and the action is
filed in a court within one year after the date of incident.
Sworn statement of proof of loss
Please complete the enclosed Sworn Statement of Proof of Loss and return it to us within 60 days. For delivery options,
please refer to the “How to submit documents” section.
Page 5 of 6
More about your loss of use coverage
Here are the loss of use benefits available to you under your policy.
Additional living expenses
Your policy provides coverage for the reasonable additional living expenses you incur because of the portion of your
property that is uninhabitable due to a covered loss. Here are some examples of items that could increase your reasonable
living expenses temporarily:
● Restaurant meals made necessary by damage to your kitchen, or if you are staying at a hotel or motel that does not
have cooking facilities.
● The cost of alternate accommodations, such as a hotel, motel or rental unit, including any necessary moving and
storage expenses, if your property is uninhabitable.
● Increased household costs for furniture rental, laundry, etc.
● Kenneling for pets if your alternate accommodations do not allow animals on the premises.
If this is your primary residence, you may instead choose to be paid the fair rental value of the damaged portion of your
property where you reside.
Fair rental value
Your policy provides for compensation of the fair rental value for that part of your insured property rented to others or held
for rental by you, if a covered incident causes that part of your property to be uninhabitable. The coverage provides for the
fair rental value of that damaged portion of the insured property uninhabitable for the shortest time needed to repair or
replace the damage up to the loss of use coverage limit.
Any payment made under this benefit will be less any expenses that do not continue while that part of your property is
uninhabitable.
Mandatory evacuation
When you are required to leave your property because it is threatened by a covered incident which might ultimately damage
your property, we are able to provide you with up to two weeks of the loss of use benefits included in your policy.
If your property is found to be damaged by the incident, a primary loss of use benefit may trigger providing a benefit for
a longer period of time.
Page 6 of 6
CSAA Insurance Exchange
PO Box 24523
Oakland, CA 94623-1523
Legal notice
California Insurance Code section 790.03.
The following are hereby defined as unfair methods of competition and unfair and deceptive acts or
practices in the business of insurance.
(a) Making, issuing, circulating, or causing to be made, issued or circulated, any estimate, illustration,
circular or statement misrepresenting the terms of any policy issued or to be issued or the
benefits or advantages promised thereby or the dividends or share of the surplus to be received
thereon, or making any false or misleading statement as to the dividends or share of surplus
previously paid on similar policies, or making any misleading representation or any
misrepresentation as to the financial condition of any insurer, or as to the legal reserve system
upon which any life insurer operates, or using any name or title of any policy or class of policies
misrepresenting the true nature thereof, or making any misrepresentation to any policyholder
insured in any company for the purpose of inducing or tending to induce the policyholder to lapse,
forfeit, or surrender his or her insurance.
(b) Making or disseminating or causing to be made or disseminated before the public in this state, in
any newspaper or other publication, or any advertising device, or by public outcry or proclamation,
or in any other manner or means whatsoever, any statement containing any assertion,
representation or statement with respect to the business of insurance or with respect to any
person in the conduct of his or her insurance business, which is untrue, deceptive, or misleading,
and which is known, or which by the exercise of reasonable care should be known, to be untrue,
deceptive, or misleading.
(c) Entering into any agreement to commit, or by any concerted action committing, any act of
boycott, coercion or intimidation resulting in or tending to result in unreasonable restraint of, or
monopoly in, the business of insurance.
(d) Filing with any supervisory or other public official, or making, publishing, disseminating, circulating,
or delivering to any person, or placing before the public, or causing directly or indirectly, to be
made, published, disseminated, circulated, delivered to any person, or placed before the public
any false statement of financial condition of an insurer with intent to deceive.
(e) Making any false entry in any book, report, or statement of any insurer with intent to deceive any
agent or examiner lawfully appointed to examine into its condition or into any of its affairs, or any
public official to whom the insurer is required by law to report, or who has authority by law to
examine into its condition or into any of its affairs, or, with like intent, willfully omitting to make a
true entry of any material fact pertaining to the business of the insurer in any book, report, or
statement of the insurer.
(f) Making or permitting any unfair discrimination between individuals of the same class and equal
expectation of life in the rates charged for any contract of life insurance or of life annuity or in the
CAS_HF23 Revised 04/15
dividends or other benefits payable thereon, or in any other of the terms and conditions of the
contract.
This subdivision shall be interpreted, for any contract of ordinary life insurance or individual life
annuity applied for and issued on or after January 1, 1981, to require differentials based upon the
sex of the individual insured or annuitant in the rates or dividends or benefits, or any combination
thereof. This requirement is satisfied if those differentials are substantially supported by valid
pertinent data segregated by sex, including, but not necessarily limited to, mortality data
segregated by sex.
However, for any contract of ordinary life insurance or individual life annuity applied for and
issued on or after January 1, 1981, but before the compliance date, in lieu of those differentials
based on data segregated by sex, rates, or dividends or benefits, or any combination thereof, for
ordinary life insurance or individual life annuity on a female life may be calculated as follows: (a)
according to an age not less than three years nor more than six years younger than the actual age
of the female insured or female annuitant, in the case of a contract of ordinary life insurance with
a face value greater than five thousand dollars ($5,000) or a contract of individual life annuity; and
(b) according to an age not more than six years younger than the actual age of the female insured,
in the case of a contract of ordinary life insurance with a face value of five thousand dollars
($5,000) or less. "Compliance date" as used in this paragraph shall mean the date or dates
established as the operative date or dates by future amendments to this code directing and
authorizing life insurers to use a mortality table containing mortality data segregated by sex for the
calculation of adjusted premiums and present values for nonforfeiture benefits and valuation
reserves as specified in Sections 10163.5 and 10489.2 or successor sections.
Notwithstanding the provisions of this subdivision, sex based differentials in rates or dividends or
benefits, or any combination thereof, shall not be required for (1) any contract of life insurance or
life annuity issued pursuant to arrangements which may be considered terms, conditions, or
privileges of employment as these terms are used in Title VII of the Civil Rights Act of 1964 (Public
Law 88-352), as amended, and (2) tax sheltered annuities for employees of public schools or of
tax exempt organizations described in Section 501(c)(3) of the Internal Revenue Code.
(g) Making or disseminating, or causing to be made or disseminated, before the public in this state, in
any newspaper or other publication, or any other advertising device, or by public outcry or
proclamation, or in any other manner or means whatever, whether directly or by implication, any
statement that a named insurer, or named insurers, are members of the California Insurance
Guarantee Association, or insured against insolvency as defined in Section 119.5. This subdivision
shall not be interpreted to prohibit any activity of the California Insurance Guarantee Association
or the commissioner authorized, directly or by implication, by Article 14.2 (commencing with
Section 1063).
(h) Knowingly committing or performing with such frequency as to indicate a general business
practice any of the following unfair claims settlement practices:
(1) Misrepresenting to claimants pertinent facts or insurance policy provisions relating to any
coverages at issue.
(2) Failing to acknowledge and act reasonably promptly upon communications with respect to
claims arising under insurance policies .
(3) Failing to adopt and implement reasonable standards for the prompt investigation and
processing of claims arising under insurance policies.
(4) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss
requirements have been completed and submitted by the insured.
(5) Not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims
in which liability has become reasonably clear.
(6) Compelling insureds to institute litigation to recover amounts due under an insurance
policy by offering substantially less than the amounts ultimately recovered in actions
brought by the insureds, when the insureds have made claims for amounts reasonably
similar to the amounts ultimately recovered.
(7) Attempting to settle a claim by an insured for less than the amount to which a reasonable
person would have believed he or she was entitled by reference to written or printed
advertising material accompanying or made part of an application.
(8) Attempting to settle claims on the basis of an application which was altered without notice
to, or knowledge or consent of, the insured, his or her representative, agent, or broker.
(9) Failing, after payment of a claim, to inform insureds or beneficiaries, upon request by them,
of the coverage under which payment has been made.
(10) Making known to insureds or claimants a practice of the insurer of appealing from
arbitration awards in favor of insureds or claimants for the purpose of compelling them to
accept settlements or compromises less than the amount awarded in arbitration.
(11) Delaying the investigation or payment of claims by requiring an insured, claimant, or the
physician of either, to submit a preliminary claim report, and then requiring the subsequent
submission of formal proof of loss forms, both of which submissions contain substantially
the same information.
(12) Failing to settle claims promptly, where liability has become apparent, under one portion of
the insurance policy coverage in order to influence settlements under other portions of the
insurance policy coverage.
(13) Failing to provide promptly a reasonable explanation of the basis relied on in the insurance
policy, in relation to the facts or applicable law, for the denial of a claim or for the offer of a
compromise settlement.
(14) Directly advising a claimant not to obtain the services of an attorney.
(15) Misleading a claimant as to the applicable statute of limitations.
(16) Delaying the payment or provision of hospital, medical, or surgical benefits for services
provided with respect to acquired immune deficiency syndrome or AIDS-related complex
for more than 60 days after the insurer has received a claim for those benefits, where the
delay in claim payment is for the purpose of investigating whether the condition preexisted
the coverage. However, this 60-day period shall not include any time during which the
insurer is awaiting a response for relevant medical information from a health care provider.
(i) Canceling or refusing to renew a policy in violation of Section 676.10.
CSAA Affinity
CSAAInsurance
Insurance Company
Exchange (“AAA”)
("AAA")
Provided In Compliance With California Insurance Code § 790.034
(ed. 10-2001)
CSAA Insurance Exchange
PO Box 24523
Oakland, CA 94623-1523
Sworn Statement In Proof of Loss
To: CSAA Insurance Exchange Named Insured on Policy:
Antwan Davis
Claim Number:
The terms of your policy require that you provide us 1005-78-2354
the following information, under oath, in support of
your claim. Date of Loss:
06/18/2024
1. Your Name:
DAVIS, ANTWAN JARMAR
Insured Address:
169 HAP ARNOLD LOOP #B ROSEVILLE,CA 95747
Mailing Address (if Different):
Home Phone Number Work Phone Number Is this policy issued in your If not, state your
( ) - (2799447472
) - ext name? relationship to the
Yes No
Named insured:
2. Generally describe the loss:
Date:6/15/24 Time: 11 AM. PM. Location: 169 HAP ARNOLD LOOP
Cause of Loss: BRAKE IN
Description of Loss:
CELL-PHONE HP-LAPTOP BANK CARDS MECHANICS TOOLS SOCKET
REFRIDGEERATOR FULL OF MISC FOOD ITEMS MEATS.FRUIT ETC- 480$ OF CLOTHES
BEDROOM TV BROKEN
3. Are you the sole owner of the damaged or stolen property? Yes No
If no, please list the name, address, and phone number of the owner or co-owner of the property, including any
lien holders or mortgages.
4. Is there other insurance issued to you or anyone else that might cover this loss? Yes No
If yes, please list the name, address, named insured, and policy number of each such policy.
5. Has there been a change in occupancy of or title to the property during the term of this policy?
CAS_F294 Revised 3/23
Please turn over
Yes No
If yes, please describe the changes.
6. Since the policy was issued, have there been any changes or additions to the damaged or stolen property?
Yes No
If yes, please describe the changes.
7. Please describe in detail the extent of damage to your property. You will also be required to complete an inventory of
damaged or stolen personal property if any, as required under the policy in Your Duties After Loss.
NOT USABLE AT ALL ELECTRONICS TO FOOD CLOTHES WHICH IS NOT IN MY HOUSEHOLD
8. Have you incurred additional expenses due to this loss? Yes No
If yes, please attach all receipts for all additional expenses incurred.
9. Is any of the damaged, lost or stolen property used in any way for business or income-producing Yes No
purposes?
If yes, please explain in detail the circumstances surrounding such use.
HOME-INTERNET LAPTOP REAL NESTATE DEALS CONTRACTS ETC. CELL PHONE CANNOT CO
10. Is this claim made under the Credit Card, Electronic Fund Transfer Card or Access Device, Yes No
Forgery and Counterfeit Money coverage?
If yes, provide all supporting documentation for such claim.
For your protection California law requires the following to appear on this form: “Any person who knowingly presents false
or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.”
I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct to the
best of my knowledge.
Date: 6/21/2024 Signature:
