Policy Number:

NGA-01695-000

Underwritten by: OLD AMERICAN COUNTY MUTUAL FIRE INSURANCE COMPANY

MARBLE FALLS, TX Policy Period:
Date Processed: 10/17/2023 Effective : 10/17/2023 01:53 PM
Expiration: 4/17/2024 12:01 AM
Coverage Provided in the Personal Auto Policy Declarations
Amended: 10/17/202301:53 PM
This declarations is subject to all of the terms and conditions of the Policy and shall
continue in force for the period shown provided the required premium is paid.

Named Insured Producer

JAVIER ALEJANDRO MEDELLIN GAITAN UNIVISTA INSURANCE (322800)
2915 FOREST HOLLOW LN 5195 NW 77TH AVE
APT 2112 MIAMI, FL 33166
ARLINGTON, TX 76006-3073 Phone: 305-508-9575
VEHICLES
VEH # ST CLASS TERR PTS S/C MILES B/U SYM. AGE YEAR MAKE MODEL/BODY TYPE VIN
1 TX SM43 194 0 N/A <=25 N 22/33 9 2016 TOYOTA COROLLA L/LE/S/SE 2T1BURHEXGC577491

LOSS PAYEE/ADDITIONAL INTEREST

VEH # LIEN HOLDER LIEN HOLDER ADDRESS

DRIVERS
DRV # NAME DOB AGE M/S SEX DRV LIC ST PTS STATUS SR22
1 JAVIER ALEJANDRO MEDELLIN GAITAN 09/15/1980 43 S M XXXXX8131 IT 0 Rated N
2 GAITAN 0 Excluded
3 MARK ANDRE HENDERSON 0 Excluded
4 DANIELLE SHIVON SAMS 0 Excluded

CURRENT COVERAGES
COVERAGES Limits of Liability RISK 1 RISK 2 RISK 3 RISK 4
Bodily Injury Liability $30,000/$60,000 per occurrence $ 294.00
Property Damage Liability $25,000 per occurrence $ 219.00
Personal Injury Protection Rejected Rejected
Uninsured Motorists – BI Rejected Rejected
Uninsured Motorist - PD Rejected Rejected
Comprehensive Veh 1: Rejected Rejected
Collision Veh 1: Rejected Rejected
Rental Veh 1: Rejected Rejected
Towing Veh 1: Rejected Rejected
VEHICLE TOTALS $ 513.00
Forms and Endorsements made part of this policy:
525 ForeignMadeDiscontinuedMakesofAuto, EsignAuth, NG-515A-010, NG-BusUse-024 (03/23), NG-ConsDisc-006 Total Premiums $513.00
(05/23), OACM 551a.Mexico Coverage-Limited, OACM.AutoTerm.007, OACM.ContLiab.006, OACM.CrimeIntent.008,
Policy Fee (Including $0.00 SR22 Fee)
OACM.DelFee.005, OACM.MisrepFraud.009, OACM.NoBusiness.020, OACM.OutOfState.016a, OACM.PhysDam.001, $72.00
OACM.YCA.002c, Spanish Consumer Bill of Rights
Motor Vehicle Crime Prevention Authority Fee
OACM.Punitive.018, OACM.RentProp-NOAuto.019a, OACM.Storage.004, OACM.TempVeh.022, OACM.ULD.023,
$2.50
(See enclosed explanation) Total Fees $74.50
Discounts: 6 Months Prior Coverage Total Policy Premiums $587.50
NOTICE: We agree to make available to you an installment payment plan as described in our Rule Manual.

NOTICE:
COUNTERSIGNED:
The effective date of the specimen policy applicable to this policy period is the most recent
date prior to the effective date shown at the top of this page, and can be viewed online at
http://nobleinsga.com/policyform.html. For a paper copy of your policy at no charge
please call (888) 512-3103 and select the underwriting option.

form: NG-DEC-002
 TEXAS LIABILITY INSURANCE CARD
POLICY NUMBER: NGA-01695-000
INSURANCE COMPANY: OLD AMERICAN COUNTY MUTUAL FIRE INSURANCE COMPANY
TO REPORT A CLAIM: 888-512-3223 VEHICLE - YEAR - MAKE - MODEL - VIN

AGENT/PRODUCER: 2016 TOYOTA COROLLA L/LE/S/SE 2T1BURHEXGC577491

322800
IHLC INSURANCE AGENCY, LLC
5195 NW 77TH AVE
MIAMI, FL 33166
305-508-9575

Warning: This Policy Contains a Named Driver Exclusion

EFFECTIVE DATE EXPIRATION DATE INCLUDED DRIVERS:
10/17/2023 4/17/2024 JAVIER ALEJANDRO MEDELLIN GAITAN

NAMED INSURED:
JAVIER ALEJANDRO MEDELLIN GAITAN
2915 FOREST HOLLOW LN
APT 2112
ARLINGTON, TX 76006-3073

If the driver(s) or vehicle(s) listed above have changed, please contact your Agent, immediately.
This policy provides at least the minimum amounts of liability Esta póliza provee por lo menos las cantidades mínimas de seguro de
insurance required by the Texas Motor Vehicle Safety Responsibility responsabilidad civil que es requerida por la ley de responsabilidad para la
Act for the specified vehicles and named insureds and may provide seguridad de los vehículos motorizados de Texas (Texas Motor Vehicle
coverage for other persons and vehicles as provided by the insurance Safety Responsibility Act) para los vehículos especificados y para los
policy. asegurados nombrados, y puede proveer una cobertura para otras
personas y vehículos según lo proporcionado en la póliza de seguro.

Texas Liability Insurance Card Tarjeta de Seguro de Responsabilidad Civil de Texas

Keep this card Guarde esta tarjeta
IMPORTANT: This card or a copy of your insurance policy IMPORTANTE: Usted debe mostrar esta tarjeta o una
must be shown when you apply for or renew your: copia de su póliza de seguro cuando solicite o renueve su:

• motor vehicle registration • registro del vehiculo motorizado

• driver's license • licencia para conducir

• motor vehicle safety inspection sticker • etiqueta de inspeccion de segurida para su vehiculo

You may also be asked to show this card or your policy if you También se puede pedir que usted muestre esta tarjeta o su
have an accident or if a peace officer asks to see it. póliza si tiene un accidente o si se la pide un oficial de policía.

All drivers in Texas must carry liability insurance on their Todos los conductores en Texas deben tener un seguro de
vehicles or otherwise meet legal requirements for financial responsabilidad civil para sus vehículos, o de lo contrario
responsibility. If you do not meet your financial deben cumplir con los requisitos legales de responsabilidad
responsibility requirements, you could be fined up to financiera. Si usted no cumple con los requisitos de
$1,000, your driver's license and motor vehicle registration responsabilidad financiera, podría estar sujeto a pagar una
could be suspended, and your vehicle could be impounded multa de hasta $1,000, mas la suspensión de su licencia de
for up to 180 days (at a cost of $15 per day). conducir y la suspensión del registro del vehículo, y además su
vehículo podría ser confiscado por hasta 180 días (a un costo
de $15 por día.

NG-IDCard-002