State Farm County Mutual Insurance Company of Texas

Auto Insurance Binder

Texas

Policy Number: 517 5370-D18-53 Agent

Named Insured(s) Ted Heaton III
JACOB PEREZ 3933 Steck Ave Suite B-111
Austin TX 78759-8648
Mailing Address (512) 343-8774
3200 Montopolis Dr
Austin TX 78744-1403 Lending Institution
RTL Auto
Vehicle 1201 OReilly Dr
Year: 2017 Lakeway TX 78734
Make: RAM
Model: PROMASTER CITY
Body Style: TRADESMAN 2WD SPORT VAN GAS
Vehicle Identification Number: ZFBERFAB0H6E38031

COVERAGES AND LIMITS

No coverage is provided for your lending institution or leasing company if Comprehensive and Collision coverages are not included on
the policy. If you did not select those coverages, you may need to contact State Farm® to discuss adding those coverages to your
policy.
The premium shown on this binder must be in compliance with the Company's rules and rates and is subject to revision. The premium
amounts do not include the additional fees required if the monthly payment plan was selected.

Coverages Applied For Limits/Deductibles Six-Month Premium

Liability - Bodily Injury / Property Damage $30,000/$60,000/$25,000 $506.58
Comprehensive Deductible $1,000 $152.60
Collision Deductible $1,000 $406.48
Total Six-Month Premium $1,065.66

PREMIUM ADJUSTMENTS
2-Star Discount
Anti-Theft Device Discount
ADDITIONAL INFORMATION
During the past 5 years has any driver or household member had a major No
violation?
During the past 3 years has any driver or household member had license No
suspended, revoked, or refused?

Policy Number: 517 5370-D18-53 Page 1 of 2

Named Insured(s): JACOB PEREZ
Effective date: 10-18-2023, Application date/time: 10-18-2023/05:27 PM CDT
1004104 IB TX.12 (rev 02/2018) 2009 144479 209 03-14-2023
Does any driver have
An at-fault accident within the last 5 years? No
A minor violation within the last 3 years? No
Primary use of vehicle? To work, school, or pleasure

NEXT STEPS
A State Farm Agent or Representative may contact you soon to inspect your vehicle and get the required documents listed
below. It is very important that you read the documents carefully. If we've requested a response, make sure you respond
before the deadline as it could have an effect on your coverage. Your State Farm agent can answer any questions you have.
Coverage Selection Rejection Form
Signature Document
TERMS AND CONDITIONS
State Farm County Mutual Insurance Company of Texas of Bloomington, Illinois, hereby binds coverage for the insurance applied
for as of the requested effective date for a period of 60 days from such date, subject to all the terms and conditions of the applicable
policy and endorsements in current use by such Company. Coverage under this binder will terminate (1) when the Declarations Page
of a policy is issued to you or (2) when canceled in accordance with law.
I apply for the insurance indicated and state that: (1) I have read this application, (2) my statements on this application are correct, (3)
statements made on any other applications on this date for automobile insurance with this company are correct and are made part of
this application, (4) I am the sole owner of the described vehicle(s) except as otherwise stated, and (5) the limits and coverages were
selected by me. It is understood and agreed that no insurance is effective under this agreement (a) unless the binder is
completed designating the company accepting this application and signed by an authorized agent of such company, or (b)
until the date the policy or binder is issued by the company accepting this application.
Consumer reports, including credit and insurance loss history reports, may be ordered in conjunction with this application to help
determine your eligibility for insurance and the price you are charged. In addition, consumer reports may be used to determine the price
you are charged at renewal. We may also obtain and use a credit-based insurance score developed from information contained in
these reports. We may use a third party in connection with the development of your insurance score. A brochure explaining how State
Farm uses consumer reports is available upon your request. For additional information, please contact your State Farm agent.

Policy Number: 517 5370-D18-53 Page 2 of 2

Named Insured(s): JACOB PEREZ
Effective date: 10-18-2023, Application date/time: 10-18-2023/05:27 PM CDT
1004104 IB TX.12 (rev 02/2018) 2009 144479 209 03-14-2023
 TEXAS TEMPORARY LIABILITY INSURANCE CARD
STATE FARM®
Texas Liability Insurance Card...This policy provides at least the minimum amounts of liability
insurance required by the Texas Motor Vehicle Safety Responsibility Act for the specified vehicle and named
insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy.
Insurance Company Vehicle-Year, Make, Model of Covered Vehicle
State Farm County Mutual Insurance 2017 RAM PROMASTER CITY TRADESMAN 2W
Company of Texas Vehicle Identification Number
Phone: 800-STATE-FARM (800-782-8332) ZFBERFAB0H6E38031
Agent or Producer 6446 NAIC # 26816
Ted Heaton III Insured
3933 Steck Ave Suite B-111 PEREZ, JACOB
Policy Number 517 5370-D18-53 3200 Montopolis Dr
Effective Date To Expiration Date Austin, TX, 78744-1403
Oct-18-2023 Dec-17-2023
Coverages
A, D1,000, G1,000 Drivers
PEREZ, JACOB

KEEP THIS LIABILITY INSURANCE CARD IN YOUR VEHICLE OR POSSESSION

Texas Liability Insurance Card Tarjeta de Seguro de Responsabilidad

Keep this card.
IMPORTANT: You must show this card or a copy of
your insurance policy when you apply for or renew
your:
• Motor vehicle registration
• Driver’s license
• Motor vehicle safety inspection sticker
You may also be asked to show this card or your
policy if you have an accident or if a peace officer
asks to see it.
All drivers in Texas must carry liability insurance on
their vehicles or otherwise meet legal requirements
for financial responsibility. If you do not meet your
financial responsibility requirements, you could be
fined up to $1,000, your driver’s license and motor
vehicle registration could be suspended, and your
vehicle could be impounded for up to 180 days (at a
cost of $15 per day).
Civil de Texas
Guarde esta tarjeta.
IMPORTANTE: Usted debe mostrar esta tarjeta o
una copia de su póliza de seguro cuando solicite o
renueve su:
• Registro del vehículo motorizado
• Licencia de conducir
• Etiqueta de inspección de segurida para su
vehículo.
También se puede pedir que usted muestre esta
tarjeta o su póliza si tiene un accidente o si se la pide
un oficial de policía.
Todos los conductores en Texas deben tener un
seguro de responsabilidad civil para sus vehículos, o
de lo contrario deben cumplir con los requisitos
legales de responsabilidad financiera. Si usted no
cumple con los requisitos de responsabilidad
financiera, podría estar sujeto a pagar una multa de
hasta $1,000, mas la suspensión de su licencia de
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).

IF YOU HAVE AN ACCIDENT- NOTIFY POLICE IMMEDIATELY

1. Get names, addresses, and phone numbers of persons involved and witnesses. Also get driver license numbers of
persons involved and license plate numbers/states of vehicles.
2. Do not admit fault, or discuss the accident with anyone but State Farm® or Police
3. Promptly notify your agent, log on to statefarm.com®, or use the State Farm mobile app to file a claim.

For EMERGENCY ROAD SERVICE use the State Farm mobile app,
log on to statefarm.com, or call 877-627-5757.
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