Texas Automobile Declaration Page

Root Lone Star Insurance Agency, Inc

Managing General Agent for
Redpoint County Mutual Insurance Company

POLICY #: M6GCKR DATE PROCESSED: 09/16/2021 10:17AM

POLICY PERIOD: September 16, 2021 at 8:31am to March 16, 2022 at 12:01am CDT.
This amended declaration reflects changes made to the policy effective September 16, 2021 at 10:17am CDT, and
replaces all previous declarations issued under this policy number.

NAMED INSURED INFORMATION

NAME(S): Ronneisha Rutherford Root Insurance Agency, LLC

MAILING ADDRESS: 715 Vassar Ct Apt C College Station, TX 77840 80 E Rich St, Suite 500
COUNTY: Columbus, OH 43215
HOME PHONE: Phone#: 866-980-9431

ENDORSEMENT REASON PREMIUM CHANGE

09/16/2021 10:17AM
$
Profile address2 changed from '' to 'Apt C'

GARAGE ADDRESS (if different than mailing)

715 Vassar Ct Apt C College Station, TX 77840

VEHICLE INFORMATION

# YEAR MAKE MODEL VIN TERR SYMBOL USAGE

1 2015 Chevrolet Equinox 2GNALBEK7F6143262

LIENHOLDER / ADDITIONAL INTEREST INFORMATION

# NAME TYPE ADDRESS

1 Smart Choice Auto Group 17650 Northwest Fwy, Houston, TX 77065

DRIVER NAME DOB GENDER MARITAL STATUS POINTS SR-22 DL STATE DL#

Ronneisha Rutherford 1990-**-** Single TX *****217

EXCLUDED DRIVERS: Excluded Drivers exist on this policy:

NAME DOB RELATION

RCM.DEC.2019
DISCOUNTS AND SURCHARGES

Applicable Discounts

Applicable Surcharges

AUTO AUTO AUTO AUTO AUTO

COVERAGES LIMITS/DEDUCTIBLES AUTO 6
1 2 3 4 5

Premium: $253
Bodily injury liability $100,000 each person $ $ $ $ $ $
$300,000 each accident

Premium: $180
Property damage liability $ $ $ $ $ $
$100,000 each accident

Premium: $49
Rental $30 each day $ $ $ $ $ $
$900 each accident

Premium: $36
Personal injury protection $ $ $ $ $ $
$5,000 each person

Premium: $64
Uninsured/underinsured
$100,000 each person $ $ $ $ $ $
motorist bodily injury
$300,000 each accident

Uninsured motorist property Premium: $0

$ $ $ $ $ $
damage DECLINED each accident

Premium: $118
Comprehensive $500 deductible. Limit of $ $ $ $ $ $
actual cash value.

Premium: $230
Collision $500 deductible. Limit of $ $ $ $ $ $
actual cash value.

$100 each incident (up to 3

Roadside assistance $ $ $ $ $ $
incidents)

Total Premium Per Vehicle $ $ $ $ $ $

Accidental Death: $ / per person $

Total Premium All

$930.00
Vehicles

SR22 Fee $

MVCPA Fee $

Policy Fee $

Down Payment $

ALL FEES ARE FULLY EARNED. THIS SUPERCEDES ANY PRIOR DATED DECLARATIONS.

RCM.DEC.2019
 APPLICABLE FORMS
Your insurance policy is available on our website: account.joinroot.com. If you want your policy mailed to you, please
call our Customer Service Team and request it to be mailed at no extra charge.

LIST OF FORMS AND EDITION DATE

The policy contract is RCM.POL.2020.09. You’ll see the form number at the bottom of the pages in your contract.
The contract is modified by forms RCM.APP.2020.08, RCM.UDE.2016, RCM.CLEE.2021, RCM.FME.2016,
RCM.MLC.2016, RCM.VDE.2020, RCM.UMCR.2016, RCM.RR.2016, and RCM.TAL.2016, which you’ll find included in
your contract.

FUTURE INSTALLMENTS / PAYMENT SCHEDULE

Description Amount Billing Date

Payment Plan Information:

If you are set up on Electronic Funds Transfer (EFT), where your insurance premiums will be withdrawn from your
checking account, the amounts listed above will be withdrawn on the dates shown. The amounts also include a monthly
installment fee.

If you are set on credit card payments, where your insurance premiums will be charged to your credit card, the amounts
listed above will be charged on the dates shown. The amounts also include a monthly installment fee.

If you are paying by invoice, your bill will be sent to you.

IMPORTANT NOTICE
NON-RENEWALS FOR NOT-AT-FAULT ACCIDENTS
OR CLAIMS
(28 TAC 5.7016)
We may not use any of the following types of accidents or claims as the only reason for refusing to renew your personal
auto policy:
1. a claim involving damage from a weather-related incident that does not involve a collision (some examples
being hail, flood, tornado, winds or hurricanes);

2. an accident or claim involving damage by contact with an animal or fowl;

3. an accident or claim involving damage caused by flying gravel, missiles or falling objects; however, if you
have three of these losses in any 36-month period, we may increase your deductible to the higher of $250
or the next available deductible increment higher than your present deductible amount, at your renewal
date;

4. a claim under towing and labor protection; however, if you have four claims of this type in any 36-month
period, we have the option of eliminating this coverage from your policy;

5. any other not-at-fault accident or claim unless there are two or more of these accidents or claims in any 12-
month period.

"Refusal to renew" means our refusal to renew your personal auto policy in the same company which originally issued
the policy. To the extent of any possible conflict between this notice and the Texas Administrative Code (28 T AC §5.
7016), the latter will be controlling.
RCM.DEC.2019
RCM.DEC.2019