Form_SCTNID_CTGRY.

GA05226489_DECPAGE

980520058 E MS03MRN INS DECPAGE E POLWHITEFONT G5SWMPVUXNHQUCCK2ESI4TV4GA0001 RPUID TRACWHITEFONT BDF_AA

MY RATE AUTO
260 GLENMOOR PATH
ALPHARETTA, GA 30005

Policy Number: 980520058

Underwritten by:
Progressive Mountain Insurance Co
June 21, 2024
RAYMOND FUQUA
Policy Period: Apr 27, 2024 - Oct 27, 2024
51 MARSHA WAY
SHARPSBURG, GA 30277 Page 1 of 2

1-404-563-1177
MY RATE AUTO
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Auto Insurance Online Service

Coverage Summary
Make payments, check billing activity, update
policy information or check status of a claim.

This is your Declarations Page 1-800-274-4499

To report a claim.

Your policy information has changed

Your coverage began on April 27, 2024 at the later of 12:01 a.m. or the effective time shown on your application. This policy period
ends on October 27, 2024 at 12:01 a.m.
This coverage summary replaces your prior one. Your insurance policy and any policy endorsements contain a full explanation of your
coverage. The policy contract is form 9611A GA (05/15) . The contract is modified by forms A263 GA (09/18) and A226 GA (06/22).

Policy changes effective June 20, 2024

………………………………………………………………………………………………………………………………………………………..
Changes requested on: Jun 20, 2024 11:49 p.m.
………………………………………………………………………………………………………………………………………………………..
Requested by: Kara Lopez
………………………………………………………………………………………………………………………………………………………..
Premium change: -$212.87
………………………………………………………………………………………………………………………………………………………..
Changes: The marital status of Raymond Fuqua has changed to married.
The marital status of Kara Lopez has changed to married.
The driving history for Kara Lopez has changed.

The changes take effect as of the date and time requested shown above.
Drivers and resident relatives
Age Gender Marital Status
………………………………………………………………………………………………………………………………………………………..
Raymond Fuqua 57 Male Married
Additional information: Named insured
………………………………………………………………………………………………………………………………………………………..
Kara Lopez 35 Female Married

Form 6489 GA (05/22)

4
Continued
980520058 E MS03MRN INS DECPAGE E POLWHITEFONT G5SWMPVUXNHQUCCK2ESI4TV4GA0001 RPUID TRACWHITEFONT BDF_AA

Policy Number: 980520058

Raymond Fuqua
Page 2 of 2

Outline of coverage
2018 NISSAN MURANO 4 DOOR WAGON
VIN: 5N1AZ2MG4JN186963
Garaging ZIP Code: 30277
Primary use of the vehicle: Pleasure/Personal
Length of vehicle ownership when policy started or vehicle added: Less than 1 month
Information regarding your vehicle history (prior damage, theft or title issues) has impacted how we determine your premium.
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability To Others $2,489
Bodily Injury Liability $25,000 each person/$50,000 each accident
Property Damage Liability $25,000 each accident
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist - Added On 471
Uninsured Motorist Bodily Injury $25,000 each person/$50,000 each accident
Uninsured Motorist Property Damage $25,000 each accident $250
………………………………………………………………………………………………………………………………………………………..
Comprehensive Actual Cash Value $2,000 92
………………………………………………………………………………………………………………………………………………………..
Collision Actual Cash Value $2,000 662
………………………………………………………………………………………………………………………………………………………..
Rental Reimbursement up to $40 each day/maximum 30 days 159
………………………………………………………………………………………………………………………………………………………..
Loan/Lease Payoff 25% Of The Actual Cash Value 43
………………………………………………………………………………………………………………………………………………………..
Total 6 month policy premium $3,916.00

Premium discounts
Policy
………………………………………………………………………………………………………………………………………………………..
980520058 Automatic Card Payments (ACP), Home Owner and Paperless
Vehicle
………………………………………………………………………………………………………………………………………………………..
2018 NISSAN Smart Technology Discount
MURANO

Smart Technology Discount ℠ is a service mark of Progressive Casualty Ins. Co.

Lienholder information
Vehicle Lienholder
………………………………………………………………………………………………………………………………………………………..
2018 NISSAN MURANO Exeter
5N1AZ2MG4JN186963 Minneapolis, MN 55439

A11Y LEH End Locator

NOTICE
The laws of the State of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim
of family violence.
Company officers

Secretary
For company use only
Year Make Model VIN Make Model Style Auxiliary
………………………………………………………………………………………………………………………………………………………..
2018 NISSAN MURANO 5N1AZ2MG4JN186963 NS MU 56 XX

Form 6489 GA (05/22) rr 202302, m MM, c A, co 24, ac MS-03MRN, fc $0.00, pc 2Z, cr B1