Form_SCTNID_CTGRY.
GA05226489_DECPAGE
990401170 N CA16464 INS DECPAGE U POLWHITEFONT JO4ASAMGM7REUJOHH2FPAGMQWA0002 RPUID TRACWHITEFONT BDF_PCA
MARTIN INS AGCY
PO BOX 51
HINESVILLE, GA 31310
Named insured Policy number: 990401170
Underwritten by:
Progressive Mountain Insurance Co
December 11, 2024
Nayef Alshami Policy Period: Dec 10, 2024 - Dec 10, 2025
307 RIVER DR Page 1 of 2
MIDWAY, GA 31320
agent.progressive.com
Online Service
Make payments, check billing activity, print
policy documents, update your policy or
check the status of a claim.
Commercial Auto 1-912-876-5115
Insurance Coverage Summary MARTIN INS AGCY
Contact your agent for personalized service.
This is your Declarations Page 1-800-444-4487
For customer service if your agent is
unavailable or to report a claim.
Your coverage began the later of December 10, 2024 at 12:01 a.m. or the effective time shown on your application. This policy period
ends on December 10, 2025 at 12:01 a.m.
Your insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown for an auto
may not be combined with the limits for the same coverage on another auto, unless the policy contract allows the stacking of limits.
The policy contract is form 6912 (02/19). The contract is modified by forms 2852GA (02/19), 4757GA (02/19), Z434 (02/19), 2366
(02/11), 2367 (06/10), 4852GA (02/19), 4881GA (02/19), Z228 (01/11) and A274GA (02/19).
The named insured organization type is a sole proprietorship.
Outline of coverage
Auto coverage part
Description Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $6,132
Bodily Injury and Property Damage Liability $1,000,000 combined
……………………………………………………………………………………………………………………………………………………….. single limit
Uninsured Motorist - Added On 321
Uninsured Motorist Bodily Injury $100,000 each person/$300,000 each accident
Uninsured Motorist Property Damage $50,000 each accident $1,000
………………………………………………………………………………………………………………………………………………………..
Medical Payments $2,000 each person 12
………………………………………………………………………………………………………………………………………………………..
Subtotal policy premium $6,465
Motor Truck Cargo coverage part
Description Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Motor Truck Cargo $100,000 $1,000 $512
………………………………………………………………………………………………………………………………………………………..
Subtotal policy premium $512
………………………………………………………………………………………………………………………………………………………..
Blanket Waiver of Subrogation Fee 75
………………………………………………………………………………………………………………………………………………………..
Blanket Additional Insured Fee 75
………………………………………………………………………………………………………………………………………………………..
Total 12 month policy premium and fees $7,127
Rated drivers
…………………………………………………………………………………………………………………………………………………..
1. Nayef Alshami
Rated commodities
…………………………………………………………………………………………………………………………………………………..
1. OTHER MISC.
4
Continued
Form 6489 GA (05/22)
990401170 N CA16464 INS DECPAGE U POLWHITEFONT JO4ASAMGM7REUJOHH2FPAGMQWA0002 RPUID TRACWHITEFONT BDF_PCA
Policy number: 990401170
Nayef Alshami
Page 2 of 2
Auto coverage schedule
1. 2006 GMC C5500
VIN: 1GDG5C1G16F904096 Garaging Zip Code: 31320 Radius: 50 miles
Personal use: N Body type: Box Truck
Liability UM-Add Med Pay
Liability Premium Premium Premium Auto Total
………………………………………………………………………………………………………………………………………………
Premium $6132 $321 $12 $6,465
Premium discount
Policy
………………………………………………………………………………………………………………………………………………………..
990401170 Electronic Funds Transfer
Additional Insured information
Blanket Additional Insured applies.
Waiver of Subrogation information
Blanket Waiver of Subrogation applies.
NOTICE
The laws of the State of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim
of family violence.
Company officers
Secretary
Form 6489 GA (05/22)
