acceptance
insurance
® Company: First Acceptance Insurance Company, Inc.
Type of Insurance: Personal Auto
We live where you do. DECLARATIONS PAGE
P.O. Box 23410
Nashville, TN 37202 Policy Number: HUGO-64884 / HUGPA7625014938
Effective Date: 02/18/2023 at 12:25PM EST
Policy Period: 02/18/2023 at 12:25PM EST to 08/18/2023 at 12:25PM EDT
Customer Service: (515) 303-2410
**********AUTO******3-DIGIT 372 Hugo Insurance
Gary Hayes 225 Santa Monica Blvd
304 N Empire Ct Santa Monica, CA, 90401
Apt 522 (515) 303-2410
Wilkes Barre, PA 18702
VEHICLE INFORMATION
The auto(s) or trailer(s) described in this policy is/are principally garaged at the above address unless otherwise stated.
VEH MODEL Deductible
NO YEAR MAKE MODEL VIN Symbol Class Points Comp/Collision
01 2018 CHEVROLET MALIBU 1G1ZD5ST3JF177469 N/A
LIENHOLDER INFORMATION
If we issue payment to the insured for comprehensive or collision insurance, we pay the insured and the following lienholder/additional interest
VEH INTEREST PHONE
NO INTEREST NAME INTEREST ADDRESS NUMBER
COVERAGES AND PREMIUMS BY VEHICLE
*If purchased, the comprehensive/collision deductible selected for each vehicle is listed in the “Vehicle Information” section.
VEH 1 VEH 2 VEH 3 VEH 4 VEH 5 VEH 6
COVERAGE LIMITS OF LIABILITY DEDUCTIBLE* PREM PREM PREM PREM PREM PREM
Bodily Injury Liability $15,000.00 / $30,000.00 $0.00 $239.00
Property Damage $5,000.00 $0.00 $251.00
First Party Medical Benefits $5,000.00 $0.00 $219.00
TORT OPTION: LIMITED
TOTAL PREMIUM PER VEH $709.00
Your policybook and amendments can be viewed at https://static.withhugo.com/pdfs/pa-acceptance-v1-policybook.pdf
[THIS POLICY DOES NOT PROVIDE ANY COVERAGE FOR WHICH A SPECIFIC PREMIUM CHARGE IS NOT MADE]
DRIVER INFORMATION
DVR DL DL SR22 / VIOL
NO DRIVER NAME DOB SEX M/S STATE STATUS FR44 PTS SSN REL STATUS
01 Gary Hayes 1985-09-11 M S PA --- NO 0 ●●●●●●●●1 Self included
PA 200 04.17 Page 1 of 2
PREMIUM SUMMARY
TOTAL PREMIUM: $709.00 PREMIUM INSTALLMENT FEE: $72.00
POLICY FEE: $30.00 TOTAL CHARGES: $811.00
ENDORSEMENTS MADE PART OF THIS POLICY AT TIME OF ISSUE
PA 100 04.17 Policy CONTRACT-EFF 1.23.2020
IF YOU PAY A PREMIUM FOR COLLISION COVERAGE, YOUR POLICY EXTENDS TO A SUBSTITUTE VEHICLE
RENTED BY YOU OR A RELATIVE FROM A LICENSED RENTAL AGENCY OR CAR DEALERSHIP, SUBJECT TO
THE DEFINITIONS AND PROVISIONS IN YOUR POLICY, INCLUDING THE DEDUCTIBLE.
This policy does not provide protection against damages caused by uninsured or underinsured motorist. If you wish to add this
important coverage, please contact your local agent so that the proper paperwork can be filled out and processed by the
company.
FRAUD WARNING NOTICE
Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
Note: If you fail to receive any of the above policy forms or endorsements or for additional copies, please contact:
Hugo Insurance Services, at support@withhugo.zendesk.com.
Discounts: We offer Passive Restraint Discount, Anti-Theft Discount and Driver Improvement Course Discount in
accordance with Title 75 of the Pennsylvania Consolidated Statutes.
Agent Countersignature
PA 200 04.17 Page 2 of 2
