POLICY NUMBER

AHW1192902 AMERICAN HEARTLAND INSURANCE COMPANY INSURED COPY

RENEWAL: PERSONAL AUTOMOBILE POLICY AGENT BILL
NOTICE: This is a limited policy. Please read the entire policy carefully. PAGE: 1
When attached to your policy, these Declarations and your application complete the policy and represent the current status of your
coverages and limits of liability according to our records. You may access copies of the policy contract and its endorsements by logging
into our website at AHILINK.COM and clicking "Forms". You may request a printed copy of this document by calling Customer
Service at 847-583-4600 during normal business hours.
Item I: Name and Address of Insured Agent: 050323 (708) 484-6300
JOAQUIN MENA FERREL AMIGO INSURANCE AGENCY INC
39 W 66TH ST APT 2 5900 W CERMAK RD STE 100
WESTMONT IL 60559 CICERO IL 60804

Item II: Policy Period (Begins and expires 12:01a.m. CST) from: 10/01/2021 to: 4/01/2022
Item III: Description of the Automobile(s)
UNT YEAR MAKE and MODEL SERIAL NUMBER SYMBOL
001 2004 SCION XB JTLKT324440160118 12-12
002 2005 FORD F-150 XL 1FTRX14W65FB32983 13-13

UNT SYM AGE TERR CLASS PTS SAFE TRNS REN ATF FLCV VSRC NOWN DEFD MC AV SM LGL ERS
001 12-12 18 15 2K 1 Y 18mo Y
002 13-13 17 15 4K 0 Y 18mo Y

Item IV: Lienholders Interests

UNT NAME ADDRESS CITY, STATE, ZIP

Item V: The insurance afforded is only as to the following coverages indicated by specific premium amounts charged, and as to such
coverages, the limit of the company's liability shall be as stated below and set forth in the policy. PREMIUM
*COVERAGES LIMITS UNIT 001 UNIT 002
A. BODILY INJURY 25,000 - EACH PERSON 50,000 - EACH ACCIDENT $49.00 $49.00
B. PROPERTY DAMAGE 20,000 - EACH ACCIDENT $51.00 $50.00
C. AUTOMOBILE MEDICAL PAYMENTS 5,000 - PER PERSON $15.00 $15.00
ACTUAL CASH VALUE LESS DEDUCTIBLE OF
UNIT 001 UNIT 002 UNIT 003
D. COMPREHENSIVE N/A N/A
E. COLLISION N/A N/A
UNINSURED MOTORIST BODILY INJURY 25,000 - EACH PERSON 50,000 - EACH ACCIDENT $36.00 $36.00
K. UNINSURED MOTORIST PROPERTY DAMAGE $250 DEDUCTIBLE - EACH ACCIDENT
TOWING
RENTAL
ADDITIONAL COVERAGES

TOTAL PREMIUM $301.00

TOTAL POLICY $301.00
*OPERATOR
NBR TYPE SR22 NAME DOB ACCIDENTS (A) VIOLATIONS (V)
1 PRIN N MENA FERREL, JOAQUIN 08/13/88 12/01/19 (V)

* In compliance with the Religious Freedom Protection and Civil Union Act (96-1513), if you are joined in a Civil Union you will be rated as "Married".
Item VI: ENDORSEMENT(S) APPLICABLE:
IL01-001A IL01-002A IL01-003A DATE 09/27/21 BY
AUTHORIZED REPRESENTATIVE
IL01-002U (08/15) Countersigned at Morton Grove, Illinois
M4104W06
Absence of entry means "no exceptions."
ILLINOIS PROOF OF INSURANCE CARD EXCLUDED/ADDITIONAL DRIVER(S):

POLICY NUMBER: AHW1192902

EFFECTIVE DATE: 10/01/2021
TO REPORT AN ACCIDENT
EXPIRATION DATE: 4/01/2022
1-800-831-8330 (or) WWW.AHILINK.COM
Named Insured FOR AN ACCIDENT RELATED TOW CALL:
Wes's Towing: 1-708-862-4949
JOAQUIN MENA FERREL

FOLD HERE
39 W 66TH ST APT 2 Examine your policy carefully.
WESTMONT IL 60559 This form does not constitute any part of your insurance policy.

Insurance coverage will start at 12:01 am CST the day after we receive your valid
Vehicle payment for this term. Valid payment is a condition of coverage and means cash,
2004 SCION XB JTLKT324440160118 money order or a check not dishonored by your bank. If your payment is not valid,
you have no coverage, even if a policy has been issued.

YOUR AGENT: AMIGO INSURANCE AGENCY INC (708) 484-6300

5900 W CERMAK RD STE 100
CICERO IL 60804
AMERICAN HEARTLAND INSURANCE COMPANY NAIC# 10031

CUT ALONG BORDER

ILLINOIS PROOF OF INSURANCE CARD EXCLUDED/ADDITIONAL DRIVER(S):

POLICY NUMBER: AHW1192902

EFFECTIVE DATE: 10/01/2021
TO REPORT AN ACCIDENT CALL
EXPIRATION DATE: 4/01/2022
1-800-831-8330 (or) WWW.AHILINK.COM
Named Insured FOR AN ACCIDENT RELATED TOW CALL:
Wes's Towing: 1-708-862-4949
JOAQUIN MENA FERREL
FOLD HERE

39 W 66TH ST APT 2 Examine your policy carefully.

WESTMONT IL 60559 This form does not constitute any part of your insurance policy.

Insurance coverage will start at 12:01 A.M. the day after we receive your valid
Vehicle payment for this term. Valid paymentVehicle
is a condition of coverage and means cash,
2005 FORD F-150 XL 1FTRX14W65FB32983 money order or a check not dishonored by your bank. If your payment is not valid,
you have no coverage, even if a policy has been issued.

YOUR AGENT: AMIGO INSURANCE AGENCY INC (708) 484-6300

5900 W CERMAK RD STE 100
CICERO IL 60804
AMERICAN HEARTLAND INSURANCE COMPANY NAIC# 10031

CUT ALONG BORDER

M4104W06