State Policy Number

Declaration Page Underwritten By: Trisura Insurance Company (Herein Company)

GA GAF20038009
Administered by: Verve Services of Georgia, LLC., PO Box 879 Pine Lake, GA 30072 (1-855-226-4466) LIC#224498

1. Declaration Date 2. Policy Effective Date 3. Policy Expiration Date 4. Policy Bound On Date & Time
08/23/2024 06/07/2024 03:12 PM ET 12/07/2024 12:01 AM ET 08/23/2024
5. Named Insured and Address 6. Agent/Producer Name and Address
FREDDY GIL SALAS United Tax Solutions
2027 Wood Terrace Rdg 5690 Roswell Rd Ste 300
Atlanta, GA 30340-3828 Sandy Springs, GA 30342-0000

The Auto(s) or trailer(s) described in this policy is principally garaged at the above address unless otherwise stated:
7 Applicable Endorsements TIC_GAPOL 12/23 TIC_GAUMREJECT 09/22 TIC_GADREXCL 09/22
(ENDORSEMENTS MUST BE LISTED BELOW IN ORDER FOR COVERAGE TO APPLY)
TIC_GAMED 09/22 TIC_GAPUNDAMAGE 09/22 TIC_GABUSREJ 09/22 DeclarationPageStateGACompany300 PolicyApplicationStateGACompany300R
Rev20220901 ev20220901

Veh. Year Make Model Body Vehicle Identification Number Symbol Territory
1 2007 Hyundai SONATA GLS Passenger 4 Door 5NPET46C37H234975 13, 13 30340
COMPASS
2 2017 JEEP SUV 1C4NJCEA2HD147818 17, 21 30340
LATITUDE/COMPASS HIGH
ALTITUDE
3 2011 HYUNDAI SONATA GLS Passenger 4 Door 5NPEB4ACXBH006040 21, 22 30340

Any loss under coverage for Damage to your auto is payable as interest may appear to named insured and (name and full address)
Veh. Name Address, City, State and Zip Code

Driver 1 Driver 2 Driver 3 Driver 4

FREDDY GIL SALAS JEAN URBINA LIGREIVER JOSE HERRERA HERNANDEZ

ALEJANDRA ORTIZ FATIMA VILLEGAS

Coverage is provided where a premium and a limit or deductible is shown for the coverage.
Coverages Limits Premiums
Each Person Each Accident Auto 1 Auto 2 Auto 3 Auto
Bodily Injury Liability
LIABILITY COVERAGE $25,000 $50,000 $274.15 $312.03 $473.37

Property Damage Liability $25,000 $152.43 $242.68 $260.04

MEDICAL PAYMENTS COVERAGE $0 N/A N/A N/A

UNINSURED/UNDERINSURED Bodily Injury Liability Coverage

N/A N/A N/A
MOTORISTS COVERAGE Rejected
($250 DEDUCTIBLE APPLICABLE
TO PROPERTY DAMAGE LIABILITY) Property Damage Liability $0 N/A N/A N/A

Deductibles
COVERAGE FOR DAMAGE TO YOUR AUTO
Auto 1 Auto 2 Auto 3 Auto
OTHER THAN COLLISION Actual Cash Value unless otherwise
N/A N/A N/A N/A N/A N/A
stated up to 40,000 MSRP
COLLISION Actual Cash Value unless otherwise
stated up to 40,000 MSRP N/A N/A N/A N/A N/A N/A
Limits
RENTAL REIMBURSEMENT (LOSS OF Per Day / Per Loss: Not Covered
USE)
TOWING AND LABOR Per Occurrence: Not Covered

TOTAL PREMIUM FOR EACH AUTO $426.58 $554.71 $733.41

SR22 Fee $0.00

MGA Fee $25.00

Total $1,739.70

DeclarationPageStateGACompany300Rev20220901 Page 1-1 DECLARATION PAGE