Endorsement Confirmation

(Confirmation # RDW6NDQ90)
Policy # 056574363
Viking Insurance Company of Wisconsin

MESA, RAYMOND C HERNAN INSURANCE SERVICES

1771 OXFORD WAY 2821 N CALIFORNIA #1
STOCKTON, CA 95204 STOCKTON, CA 95204
(209) 688-4796 (209) 467-0406

Agency Code: 0504416

Policy Term Program Original Inception Date

07/04/2018 - 08/04/2018 Monthly 08/10/2009

Summary of Changes
Effective: 08/02/2018
Submitted: 8/2/2018 04:24:59 PM (CT)
Producer/CSR Name: Company

Change Details
Add
Vehicle: 1994 CHEVROLET CORVETTE 1G1YY22P1R5104944

1994 CHEVROLET CORVETTE 1G1YY22P1R5104944: UM-PD: Reject

GN3131 (4/12)
Page 1 of 1 (RAYMOND C MESA; Conf # RDW6NDQ90)
Viking Insurance Company of Wisconsin
CALIFORNIA UNINSURED MOTORISTS COVERAGE
SELECTION/REJECTIONS
Named Insured Policy Number
MESA, RAYMOND C 056574363

REJECTION OF "UNINSURED MOTORISTS-PROPERTY DAMAGE" COVERAGE

"The California Insurance Code requires an insurer to offer coverage for damage to the insured motor vehicle, to the
extent that you are legally entitled to recover, from the owner or operator of the uninsured motor vehicle, caused by an
uninsured motor vehicle, that either:
(1) Pays the collision deductible on the insured motor vehicle (when you have purchased collision coverage), or
(2) Pays for the damage to the insured motor vehicle (when you have not purchased collision coverage).
Payment does not include damage to personal property or loss of use of a motor vehicle and shall not exceed the smaller
of any of the following:
(A) The amount of the collision deductible, or
(B) The actual cash value of the loss or damage to the insured motor vehicle, or
(C) $3,500.
You may reject such coverage completely or reject such coverage when an insured motor vehicle is operated by a natural
person or persons designated by name."
* I have read and have understood the above information, and I decided not to purchase this coverage.

NI1-1ND NI1-D

Named Insured's Signature Date

CA1207 (11/11)
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make CHEV Year 1994 Effective Date 07/04/2018
Model CORVETTE Expiration Date 08/04/2018
I.D. Number 1G1YY22P1R5104944
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make TOYO Year 1997 Effective Date 07/04/2018
Model TERCEL CE/HAWK LTD. Expiration Date 08/04/2018
I.D. Number JT2BC52L3V0262891
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make JEEP Year 1992 Effective Date 07/04/2018
Model CHEROKEE BRIARWOOD Expiration Date 08/04/2018
I.D. Number 1J4FN78SXNL101752
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make MAZD Year 1992 Effective Date 07/04/2018
Model B2200 Expiration Date 08/04/2018
I.D. Number JM2UF1230N0297769
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make CHEV Year 1994 Effective Date 07/04/2018
Model CORVETTE Expiration Date 08/04/2018
I.D. Number 1G1YY22P1R5104944
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make TOYO Year 1997 Effective Date 07/04/2018
Model TERCEL CE/HAWK LTD. Expiration Date 08/04/2018
I.D. Number JT2BC52L3V0262891
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make JEEP Year 1992 Effective Date 07/04/2018
Model CHEROKEE BRIARWOOD Expiration Date 08/04/2018
I.D. Number 1J4FN78SXNL101752
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.
CALIFORNIA AUTOMOBILE INSURANCE IDENTIFICATION CARD
Viking Insurance Company of Wisconsin NAIC 13137
Policy # 056574363
Make MAZD Year 1992 Effective Date 07/04/2018
Model B2200 Expiration Date 08/04/2018
I.D. Number JM2UF1230N0297769
Insured
MESA, RAYMOND C
1771 OXFORD WAY
STOCKTON, CA 95204

Producer Producer # 0504416

HERNAN INSURANCE SERVICES Producer Phone # (209) 467-0406
2821 N CALIFORNIA #1
STOCKTON, CA 95204

If you are in an accident, call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.
(See reverse side for additional information.)
GN3000 (11/10)

FOLD HERE

IN CASE OF AN ACCIDENT
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.

...then call us IMMEDIATELY at 1-800-334-0090.

We are available 24 hours a day to take your call.

COVERAGE COMPLIES WITH MINIMUM AMOUNT OF LIABILITY INSURANCE REQUIRED.

YOU ARE REQUIRED TO KEEP THIS CARD IN YOUR POSSESSION AND PRODUCE IT
UPON DEMAND.

THIS CARD SERVES AS SATISFACTORY EVIDENCE IF ASKED TO VERIFY FINANCIAL

RESPONSIBILITY.

THIS CARD IS NOT PART OF YOUR POLICY AND IS EFFECTIVE ONLY WHILE YOUR
INSURANCE REMAINS IN FORCE. THIS CARD NEITHER AFFIRMATIVELY OR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE AFFORDED BY YOUR POLICY.