State Policy Number

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

GA GAF20049182
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 Change Date and Time
10/02/2024 10/02/2024 10:24 AM ET 04/02/2025 12:01 AM ET 10/02/2024 10:24 AM ET
5. Named Insured and Address 6. Agent/Producer Name and Address
Gabriel Williams Bensomont Inc dba Velox Insurance
370 Northside Dr NW 11324 Tara Blvd
Atlanta, GA 30318-7038 Hampton, GA 30228-0000

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 2010 Toyota RAV4 SUV JTMBF4DVXA5029210 13, 13 30318

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

Gabriel Williams

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 Auto Auto
Bodily Injury Liability
LIABILITY COVERAGE $25,000 $50,000 $1,245.65

Property Damage Liability $25,000 $801.05

MEDICAL PAYMENTS COVERAGE $0 N/A

UNINSURED/UNDERINSURED Bodily Injury Liability Coverage

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

Deductibles
COVERAGE FOR DAMAGE TO YOUR AUTO
Auto 1 Auto Auto Auto
OTHER THAN COLLISION Actual Cash Value unless otherwise
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
Limits
RENTAL REIMBURSEMENT (LOSS OF Per Day / Per Loss: Not Covered
USE)
TOWING AND LABOR Per Occurrence: Not Covered

TOTAL PREMIUM FOR EACH AUTO $2,046.70

SR22 Fee $0.00

MGA Fee $25.00

Total $2,071.70

DeclarationPageStateGACompany300Rev20220901 Page 1-1 DECLARATION PAGE