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    Dec 2

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    Dec 2

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    Dec-2

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    45 views2 pages

    Dec 2

    Uploaded by

    piter.ayrout

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    of 2

    PERSONAL CAR POLICY DECLARATIONS

    AssuranceAmerica Insurance Company (800) 450-7857


    PO BOX 723128 ATLANTA, GA 31139-0128
    Agent: SELECT INSURANCE GROUP
    Code: FL2963 Agent Phone: (407) 275-6102

    Policy Number: PFL2178825


    Notice Date: 01/06/2024 Policy Period: 01/06/2024 05:55 PM
    Named Insured: 07/06/2024 12:01 AM

    Piter Ayrout
    5208 Tuscany Ln
    Davenport, FL 33897-3605
    POLICY TOTAL: $561.00

    New Business Declarations


    Driver(s) Listed DOB Pts Driver(s) Excluded or Not Rated DOB
    1 Piter Ayrout 09/21/1984 0 None
    2 Marielena Rodriguez 09/04/1986 0
    Vehicle(s) VIN Zip Driver Usage Lienholder
    1 2008 Kia Sedona KNDMB233486199432 33897 37MF P
    Coverages Limits and/or Deductibles VEH 1
    Property Damage Liability $11,000 per accident $232
    Personal Injury Protection $10,000 per person/$1000 Ded (NIRR) $294
    Accidental Death & Dismemberment $1,000 $0
    Total Premium per Vehicle: $526

    Policy Fee: $25.00, Installment Setup Fee: $10.00


    Forms and Endorsements: Form 06-FL (05/22), FLOUTLINE ECON (03/15)

    Discounts/Surcharges Applied: Safe Driver, Wage Loss, Recurring Electronic Payment, E-Sign at Bind, Air Bag-V1, Anti
    Lock Brakes-V1

    Page 1 of 1
    FLORIDA AUTOMOBILE INSURANCE
    IDENTIFICATION CARD

    AssuranceAmerica Insurance Company

    POLICY# PFL2178825 FLORIDA CODE: 03674

    EFFECTIVE DATE
    01/06/2024
    PERSONAL INJURY BODILY
    ✔
    PROTECTION INJURY
    BENEFITS/ LIABILITY
    PROPERTY
    DAMAGE LIABILITY

    NAME INSURED:
    Piter Ayrout
    YEAR: 2008 MAKE: KIA

    VIN: KNDMB233486199432

    MODEL: Sedona

    SELECT INSURANCE GROUP


    (407) 275-6102

    NOT VALID FOR MORE THAN ONE


    YEAR FROM EFFECTIVE DATE

    THIS CARD MUST BE KEPT IN THE


    INSURED VEHICLE AND
    PRESENTED UPON DEMAND:

    CALL (800) 450-7857 TO REPORT


    YOUR CLAIM.

    IN CASE OF ACCIDENT: Report all


    accidents to your Agent/Company as soon
    as possible. Obtain the following
    information.
    1. Name and address of each driver,
    passenger and witness.
    2. Name of Insurance Company and
    policy number for each vehicle
    involved.

    MISREPRESENTATION OF INSURANCE
    IS A FIRST DEGREE MISDEMEANOR

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