C2402 Orange Coast Claims 032258 CAPA-02087560

P.O. Box 10730

Santa Ana, CA 92711-0730
888-263-7287

August 29, 2023

LOUIS VALENTE
7375 la mesita pl
la mesa, CA 91942

RE: OUR INSURED: LOUIS VALENTE

OUR CLAIM NUMBER: CAPA-02087560
DATE OF LOSS: MARCH 18, 2023
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Dear LOUIS VALENTE:
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In the event we offer your policy limits to the claimant, we will need a signed declaration from you
confirming you had no excess liability coverage, and you were not acting in the course and scope of
your employment. Please review and, if accurate, sign the declaration below.

Please do not hesitate to contact me if you have any questions.

Sincerely,
Mercury Insurance Company

Luis Villalobos for Nicholas Ortega

Claims Department
888-263-7287, ext. 21576

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I declare under the penalty of perjury that the statements below are true and correct:
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I, _____________________________, had no excess liability insurance on the date of this loss.

My _________________________________________ auto policy was my sole form of liability

coverage at the time of this loss.

Signature: _______________________________ Date: ___________________

I, ________________________________, was not working for any employer at the time of the
accident, nor was I performing an errand or task for any other person.

Signature: ________________________________ Date: ___________________

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C226 04/2021