LOUISIANA AUTO INSURANCE IDENTIFICATION CARD

An insurer authorized to transact business in Louisiana has issued the Motor Vehicle Policy identified hereon. The coverage
provided by this policy meets the minimum liability insurance limits prescribed by law.
Imperial Fire & Casualty Insurance Company
KRISTOFFER MELDER
PO Box 3199 ● Winston Salem, NC 27102-3199
4135 Highway 112
Forest Hill, LA 71430 NAIC POLICY NUMBER
44369 2020168288
Policy Term Effective Date Policy Term Expiration Date
09/22/2023 03/22/2024
Report all accidents by calling:
1-800-468-3466
AGENCY: 83906 VEHICLE INFORMATION
Usagencies-709 YEAR MAKE VIN
440 3rd St Fl 8 1995 FORD 2FALP73W5SX154070
Baton Rouge LA 70802 This card must be carried in the vehicle at all times
Phone: (800) 958-8545 as evidence of liability insurance.
EXCLUDED DRIVERS:

IMPORTANT NOTICE - La. R.S. 32:863.1 requires that an operator of a motor vehicle produce upon demand by a law enforcement officer documentation of
motor vehicle security which is required to be maintained within the vehicle at all times. Failure to comply may result in fines, revocation of registration
privileges and block against the renewal or issuance of a driver's license.
MOD 00 11840 (09012016)

Cut on Solid Line – Store In Your Vehicle

 Policy Number: Date of Notice
2020168288 09/22/2023 04:35 PM
PO Box 3199 ● Winston Salem, NC 27102-3199 Named Insured:
KRISTOFFER MELDER

KRISTOFFER MELDER Policy Period:

4135 HIGHWAY 112 09/22/2023 - 03/22/2024
FOREST HILL, LA 71430 Policy Underwritten by:
Imperial Fire & Casualty Insurance Company

24 Hour Claim Reporting: 1-800-468-3466

For Policy Information: 1-877-468-3466
www.MyNatGenPolicy.com
Your Agent:
Usagencies-709
440 3rd St Fl 8
Baton Rouge LA 70802
(800) 958-8545

LA PERSONAL AUTO DECLARATIONS PAGE

New Business Effective 09/22/2023 04:35 PM

Drivers and Household Residents

#1 KRISTOFFER MELDER
Driver Status License # Lic. State Date of Birth Gender Marital Status Driver Pts Yrs. Lic.
Rated Driver XXXXX3712 LA 04/04/1978 Male Single 0 29

Insured Personal Auto(s) and Schedule of Coverages

#1 1995 FORD CROWN VI VIN: 2FALP73W5SX154070-FE3134
Usage: Pleasure/Commute
Garaging Location: 71430
Coverages Provided Limits/Deductibles Premium
Bodily Injury $15,000 Each Person / $30,000 Each Accident $465.00
Property Damage $25,000 Each Accident $281.00
Total For This Vehicle $746.00

Premium and Fee Totals

Combined Vehicle Coverage Premium $746.00
Acquisition Expense $50.00
Motor Vehicle Record Fee $5.00
Total 6 Month Policy Premium $801.00

Discounts Applied
Policy Level
Accident Free Claims Free
Paperless Discount

Additional Policy Information

Insured email: MELDERKRISTOFFER@GMAIL.COM
Tier: 3

10039LA (02012019)
Disclosure of Possible Additional Charges
The amounts below are authorized for use in this state. However, they are only charged if they apply to your policy.
Convenience Fee $3.00
Financial Responsibility Filing Fee $20.00
Late Charge $15.00
Nonsufficient Funds Charge $35.00
Reinstatement Charge $30.00
Renters Fee $25.00
MVR Fee $5.00

Forms and Endorsements

Form Edition Form Name
12396 02012019 PERSONAL AUTO POLICY

Authorized Signature

10039LA (02012019)