Country-Wide Insurance Company
40 Wall Street
New York, NY 10005
Policy Number: DS 2124675 Eff. Date: 04/11/2022 Eff. Time: 13:49
33
Insured's Name JOSE VARGAS
Address 10231 SW 4TH CT UNIT 406 PEMBROKE
PINES, FL 33025
Home Phone N/A
Work Phone
Cell Phone N/A
Employer's Name ARECIBO CAR SERVICE
Address 171 5 5 AVE
BROOKLYN, NY 11217
Broker Code B02592
Broker Phone Number 718-565-6320
The following item(s) MUST BE mailed to the company within 7 business days.
- Copy of foreign license and notarized translation (if mark YES for foreign license)
* IF THE PREVIOUS CARRIER WAS AN ASSIGNED RISK POLICY, PLEASE FAX THE
PRIOR DECLARATIONS PAGE TO 212-381-1005.
* All vehicles must be registered to the named insured. Please do not issue ID cards in any other name.
Only married couples can be listed as named insureds.
Policy Number: DS 2124675
33 1
Company Informa�on:
Country-Wide Insurance Company
40 Wall Street, New York, NY 10005
Broker Informa�on:
Agency Name: Pacifico Travel Inc. Policy #: DS 212467533
Address: 111-15a Roosevelt Ave. Market: Deluxe Saver
Corona, New York 11368
Producer B/K number: B02592
(Do Not Retain Commission)
--------------------------------------- General Informa�on ---------------------------------------
Home Tel N/A Eff Date 04/11/2022
Insured Name JOSE VARGAS PT T or4kRel. Eff Time 13:49
Address 10231 SW 4TH CT UNIT 406 PEMBROKE, FL 33025 N/A Policy Term Two Month
Cell Tel.
--------------------------------------- Driver Informa�on ---------------------------------------
Complete for Applicant, Spouse, and all persons age 16 and over residing with Applicant (Licensed or not).
Also list any operators.
Driver # Driver's Name Birth Date Age Sex Marital Status Relation
1 JOSE VARGAS 08/20/1979 42 Male Single
2
3
4
Driver # License Number State Social Security Number Principal/Occasional
1 N/A
2
3
4
--------------------------------------- Vehicle Information ---------------------------------------
Vehicle # Year Make Model Type Body Type CYL Turbo
1 16 BMW X5 SUV
2
3
4
Vehicle # Symbol Vehicle Identification # Garaging Zip Vehicle Usage Driver # Points
1 17 5UXR0C59G0S93217 Pleasure
2
3
4
PLEASE INFORM APPLICANT THAT FAILURE TO DISCLOSE ALL DRIVERS/RESIDENTS OF
HOUSEHOLD, AND ALL ACCIDENTS/VIOLATIONS CAN VOID COVERAGE OR CAUSE PREMIUM
UPRATE AND/OR POLICY CANCELLATION.
--------------------------------------- PREVIOUS CARRIER ---------------------------------------
Company Name: NONE Exp. Date: 06/10/2022
Policy Number: DS 2124675
33 2
APPLICANT'S SIGNATURE
I hereby declare that the statements contained herein are true to the best of my knowledge and belief and
do hereby agree to pay any surcharges applicable under Company rules which are necessitated by
inaccurate statements. I agree that my policy will be cancelled if my payment is not honored by the Bank.
I hereby declare that no persons, other than those listed on the front of this application, regularly
operate the vehicle(s) described on this application. I understand that this policy may be canceled if
this application contains any false information or if any information that would alter the Company's
exposure is omitted or misrepresented.
I understand that a service fee of $13.00 will be added to the balance due on my policy for each
installment in the payment plan I select.
I understand that a Non-Sufficient Funds (NSF) charge of $30.00 will be added to the balance due on my
policy, if any payment made is not honored by my bank or credit card company. Imposition of such charge
shall not deem the Company to have accepted the check unconditionally.
I understand that a $35.00 late fee will be added to the balance due on my policy if the premium payment
is received after the due date on the invoice.
I understand that a $50.00 reinstatement fee will be added to the balance due on my policy if the premium
payment is received after the cancellation date and the Company agrees to reinstate the policy.
I agree that if I pay my initial premium by check, the coverage afforded by this policy is conditioned on
the check being honored by the bank when presented for payment. If the check is not honored, Company
shall be deemed not to have accepted the check, and this policy shall be cancelled.
I understand that a cancellation fee of $50.00 will be added to the balance due on my policy if it is
cancelled for any reason during the first 6 months of the initial policy period and that amount may be
deducted from any refund due to me.
Note: In connection with your request for a premium quotation:
(1) we may obtain consumer reports or personal or privileged information from third parties;
(2) in certain circumstances, such information, as well as other personal privileged information
subsequently collected by us, may be disclosed to third parties without your authorization, but it
is not our practice to do so;
(3) you have the right to access and correct all personal information collected; and
(4) at your request we will: (a) confirm whether a consumer report was requested and, if so, provide the
name and address of the consumer reporting agency that furnished it; and (b) provide you more
detailed information regarding our collection, use, and disclosure of personal information, and rights
to access and correct such information.
NEW YORK STATE INSURANCE DEPARTMENT - REGULATION 95
Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make
a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement
agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act,
which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the
value of the subject motor vehicle or stated claim for each violation.
JOSE VARGAS Date: 04/11/2022
Signature of Insured-Applicant
I understand and have agreed to the limits of coverage within my automobile insurance policy, as well as
the coverages applicable to the policy.
JOSE VARGAS Date: 04/11/2022
_ignature of Insured-Applicant
S
The undersigned hereby warrants and certifies that the information contained herein is correct to the best
of his/her knowledge; that this application was completed and then signed by the insured-applicant; that
a completed copy hereof has been given to the insured-applicant; and that the undersigned has a duplicate
signed copy hereof.
JOSE VARGAS Date: 04/11/2022
Policy Number: DS 2124675
21
3
Electronic Signature Details
JOSE VARGAS
By selection of this space and completion of the below information, I the above named insured-
applicant, hereby attest that I make this selection and entry AS MY ELECTRONIC SIGNATURE
in place of a physical signature.
AND
I understand and have agreed to the limits of coverage within my automobile insurance policy,
as well as the coverages applicable to the policy.
AND
I the undersigned hereby warrants and certifies that the information contained herein is correct
to the best of his/her knowledge; that this application was completed and signed by the insured-
applicant; that a completed copy has been hereof has been given to the insured-applicant; and
that the undersigned has a duplicate signed copy hereof.
AND
I certify that I have read the above REGULATION 95 statement.
Name: JOSE VARGAS
EMail:
Policy Number: DS 2124675
33 4
Rating Table
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
DISCOUNTS
Passive Restraints 343
ABS / DRL 78
Anti-Theft
Defensive Driving 116
Driver Training 0
Careful Driver 0
Multiple Car 0
COVERAGES
Bodily Injury (25/50) 347.0
Property Damage (10,000) 207.0
Personal Injury (200) 722
Add'l PIP (Basic PIP 50000) 0.0
OBEL 0
Medical Payments
Uninsured Motorist (25/50) 54.0
Death Benefits
Towing
Rental Reimbursement (None)
Comprehensive (None)
Full Glass Coverage
Voluntary
Collision
NY DMV Fee 10
Total 1340
Grand Total 1340.0
Payment Breakdown
Payment Date Amount($)
PAYMENT 1 04/11/2022 148
Total Premium 148
(Include installment charges)
Policy Number: DS 2124675
33 5
.
FAX: Scanable Bar Code
DO NOT DESTROY FAX INSTRUCTIONS:
1. The entire page must be faxed.
THESE ARE YOUR ORIGINAL I.D. CARDS
2. If submitted to DMV, either the entire page or the second ID card and large scanable barcode
PLEASE CUT ON DOTTED LINE. will be retained.
3. A faxed ID card must be replaced with a scanable ID card within 14 days of the effective date.
Phone Payment User Id 01033064675 Password 67516
Customer Service Ph: (212) 440 - 5160 4. DMV will not accept a faxed ID card without a scanable barcode.
NEW YORK STATE INSURANCE IDENTIFICATION CARD THIS ID CARD MUST BE CARRIED
410 COUNTRY-WIDE INSURANCE COMPANY Policy Number IN THE INSURED VEHICLE FOR
DS 212467533 PRODUCTION UPON DEMAND
Name & Address of Issuer COUN
UNT
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40 WA
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005 Effective Date Expiration Date WARNING: Any person who issues
04/11/2022 06/10/2022 or produces an ID card knowing that
10:10 a.m. 10:10 a.m.
an Owner's Policy of Insurance is not in
(Not acceptable to obtain registration
An authorized NEW YORK insurer has issued an Owner's Policy of after 45 days from effective date.) effect may be committing a misdemeanor.
Liability Insurance complying with Article 6 (Motor Vehicle Financial Applicable with respect to the following In addition, a person who presents an
Security Act) of the NEW YORK Vehicle and Traffic Law to: Motor Vehicle:
ID card if insurance is not in effect
2016 BMW
may be committing a misdemeanor.
JOSE VARGAS10231 SW 4TH CT UNIT 406 PEMBROK Year Make
E PINES, FL 33025
5UXR0C59G0S93217 The name of the registrant and the
Vehicle Identification Number name of the insured must coincide.
REPLACEMENT VEHICLE NOTATION:
DMV WILL ONLY PROCESS A VEHICLE
CHANGE (RE-REGISTRATION) USING
THE REPLACED VEHICLE'S CURRENT
REGISTRATION.
FS-20
NEW YORK STATE INSURANCE IDENTIFICATION CARD THIS ID CARD MUST BE CARRIED
410 COUNTRY-WIDE INSURANCE COMPANY Policy Number IN THE INSURED VEHICLE FOR
Name & Address of Issuer CO
COUNTRTRY-WID IDE INSU
SURANCE
CE C
COO DS 212467533 PRODUCTION UPON DEMAND
40 WA
40 WALLLL ST
S TR
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NEW
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K,, NYY 10
100
005
05 Effective Date Expiration Date
04/11/2022 06/10/2022
or produces an ID card knowing that
10:10 a.m. 10:10 a.m.
(Not acceptable to obtain registration an Owner's Policy of Insurance is not in
An authorized NEW YORK insurer has issued an Owner's Policy of after 45 days from effective date.) effect may be committing a misdemeanor.
Liability Insurance complying with Article 6 (Motor Vehicle Financial Applicable with respect to the following
Security Act) of the NEW YORK Vehicle and Traffic Law to: Motor Vehicle In addition, a person who presents an
2016 BMW ID card if insurance is not in effect
Year Make may be committing a misdemeanor.
JOSE VARGAS10231 SW 4TH CT UNIT 406 PEMBROK
E PINES, FL 33025
5UXR0C59G0S93217 The name of the registrant and the
Vehicle Identification Number name of the insured must coincide.
REPLACEMENT VEHICLE NOTATION:
DMV WILL ONLY PROCESS A VEHICLE
CHANGE (RE-REGISTRATION) USING
THE REPLACED VEHICLE'S CURRENT
REGISTRATION.
FS-20
WIDCARD2B
THIS CARD MUST BE CARRIED IN THE INSURED VEHICLE FOR PRODUCT ION UPON DEMAND
WARNING: Any person who issues or produces an ID card knowing that an Owner's Policy of Insurance
is not in effect may be committing a misdemeanor. In addition, a person who presents
an ID card if Insurance is not in effect may be committing a misdemeanor.
IN CASE OF ACCIDENT DAY OR NIGHT CALL COLLECT: (212) 344-8700
WHAT TO DO IN CASE OF ACCIDENT
1. Do not admit liability. Make no comment or statement regarding accident to anyone except to an identified representative of this Company or, if necessary, to the police.
2. Record date, time and place of accident and all facts and conditions which caused or contributed to accident.
3. Obtain and record names, addresses and telephone numbers of all occupants, witnesses and police officers.
4. Obtain and record (a) names and addresses of owners and (b) operators of all other vehicles involved in accident, (c) registration numbers of such vehicles,
(d) license numbers of operators and (e) description of vehicles.
5. Obtain name, address and age of each person sustaining bodily injury. Ascertain extent of such injury and name and address of hospital or physician rendering emergency treatment.
6. Ascertain extent of property damage.
7. Immediately report accident to Home Office of Company or to its nearest authorized representative no matter how minor the accident appears to be.
8. 1 00K BODILY P.P /300K INJURY P.A/ 50K PROPERTY DAMAGE.
PLEASE SPECIFY POLICY NUMBER, NAME AND ADDRESS OF INSURED WHEN REPORTING ACCIDENT TO COMPANY
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THIS CARD MUST BE CARRIED IN THE INSURED VEHICLE FOR PRODUCTION UPON DEMAND
WARNING: Any person who issues or produces an ID card knowing that an Owner's Policy of Insurance
is not in effect may be committing a misdemeanor. In addition, a person who presents
an ID card if Insurance is not in effect may be committing a misdemeanor.
IN CASE OF AC
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344-87
700
WHAT TO DO IN CASE OF ACCIDENT
1. Do not admit liability. Make no comment or statement regarding accident to anyone except to an identified representative of this Company or, if necessary, to the police.
2. Record date, time and place of accident and all facts and conditions which caused or contributed to accident.
3. Obtain and record names, addresses and telephone numbers of all occupants, witnesses and police officers.
4. Obtain and record (a) names and addresses of owners and (b) operators of all other vehicles involved in accident, (c) registration numbers of such vehicles,
(d) license numbers of operators and (e) description of vehicles.
5. Obtain name, address and age of each person sustaining bodily injury. Ascertain extent of such injury and name and address of hospital or physician rendering emergency treatment.
6. Ascertain extent of property damage.
7. Immediately report accident to Home Office of Company or to its nearest authorized representative no matter how minor the accident appears to be.
8. Do not engage in any controversies at the scene of accident. Leave the entire handling of any claim to this Company's representatives.
PLEASE SPECIFY POLICY NUMBER, NAME AND ADDRESS OF INSURED WHEN REPORTING ACCIDENT TO COMPANY
COUN
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