DocuSign Envelope ID: 1977DC75-BB87-4F0B-B97B-3417EB11B8B4

Venture General Agency Policy Number:

OLD AMERICAN COUNTY MUTUAL FIRE INSURANCE COMPANY
VGAL-296380-000
HORSESHOE BAY, TX
Date Processed:
Policy Period:
Coverage Provided in the Effective : 11/19/2018 [Link]
Personal Auto Policy Declarations Expiration: 05/19/2019 12:01 AM
Amended:

This declarations is subject to all of the terms and conditions of the Policy and shall continue
in force for the period shown provided the required premium is paid.
Named Insured Producer
ANTHONY MICHAEL CARLOCK A-MAX INSURANCE SERVICES, INC (12819500)
2247 BALD EAGLE WAY 1111 W MOCKINGBIRD LN
GRAND PRAIRIE, TX 75052 STE 1190
DALLAS, TX 75247
Vehicles
VEH# ST CLASS TERR PTS S/C MILES B/U SYM. AGE YEAR MAKE MODEL/BODY TYPE VIN
1 SM21 84 0 N/A <=25 N 12 / 12 16 2002 TOYOTA/CAMRY LE/CAMRY SE/CAMRY
4T1BE30K92U039268
XLE

LOSS PAYEE/ADDITIONAL INTEREST

VEH# LIEN HOLDER LIEN HOLDER ADDRESS

DRIVERS
DRV # NAME DOB AGE M/S SEX DRV LIC ST PTS STATUS SR22
1 ANTHONY MICHAEL CARLOCK 09/28/1997 21 S M 41777149 TX 0 Rated N
2 MICHELLE RENEE HENDERSON 10/26/1968 50 S TX 0 Excluded
3 DERRIN DAMAN CHAMBERS 06/14/1969 49 S TX 0 Excluded
4 ALEXXUS MARIE CHAMBERS S 0 Excluded
CURRENT COVERAGES
COVERAGES Limits of liability Veh# 1
Bodily Injury Liability $30,000/$60,000 $297.00
Property Damage Liability $25,000 $341.00
Personal Injury Protection Rejected
Uninsured Motorists – BI Rejected
Uninsured Motorist - PD Rejected
Comprehensive Veh 1: Rejected
Collision Veh 1: Rejected
Rental Veh 1: Rejected
Towing Veh 1: Rejected

VEHICLE TOTALS $638.00

Forms and Endorsements made part of this policy: Total Premiums $638.00
515A,[Link].003a,[Link].007,[Link].006,[Link]. Installment Fee $18.00
013c,[Link].008,[Link].010,[Link]. $ 72.00
Policy Fee (Including 0 SR22 Fee)
005,[Link].009,[Link].020,[Link].
016,[Link].001,[Link].018,[Link]-NOAuto. Automobile Burglary and Theft Prevention Authority $1.00
019,[Link].012a,[Link].004,[Link].002 Fee (See enclosed explanation) Total Fees $ 91.00
Discounts: Total Policy Premiums $729.00
NOTICE: We agree to make available to you an installment payment plan as described in Rule 14 of the Texas Automobile Rules and Rating Manual,
except when an installment plan is prohibited by other rule or statute

NOTICE:
COUNTERSIGNED:
The effective date of the specimen policy applicable to this policy period is the most recent
date prior to the effective date shown at the top of this page, and can be viewed online at
[Link] For a paper copy of your policy at no charge
please call (855) 480-3755 and select the underwriting option.

form: VG-DEC-002
DocuSign Envelope ID: 1977DC75-BB87-4F0B-B97B-3417EB11B8B4
TEXAS LIABILITY INSURANCE CARD
POLICY NUMBER: VGAL-296380-000
INSURANCE COMPANY: OLD AMERICAN COUNTY MUTUAL FIRE INSURANCE COMPANY TO
REPORT A CLAIM: 855-480-3755 VEHICLE - YEAR - MAKE - MODEL - VIN
AGENT/PRODUCER: 2002 TOYOTA CAMRY LE/CAMRY SE/CAMRY4T1BE30K92U039268
XLE

A-MAX INSURANCE SERVICES,

INC
1111 W MOCKINGBIRD LN
STE 1190
DALLAS, TX 75247
800-979-2629 Warning: This Policy Contains a Named Driver Exclusion
EFFECTIVE DATE EXPIRATION DATE INCLUDED DRIVERS:
11/19/2018 05/19/2019 ANTHONY MICHAEL CARLOCK

NAMED INSURED:
ANTHONY MICHAEL CARLOCK
2247 BALD EAGLE WAY
GRAND PRAIRIE, TX 75052

If the driver(s) or vehicle(s) listed above have changed, please contact your Agent, immediately.
Esta póliza provee por lo menos las cantidades mínimas de seguro de
This policy provides at least the minimum amounts of liability responsabilidad civil que es requerida por la ley de responsabilidad para la
insurance required by the Texas Motor Vehicle Safety Responsibility seguridad de los vehículos motorizados de Texas (Texas Motor Vehicle
Act for the specified vehicles and named insureds and may provide Safety Responsibility Act) para los vehículos especificados y para los
coverage for other persons and vehicles as provided by the insurance asegurados nombrados, y puede proveer una cobertura para otras
policy. personas y vehículos según lo proporcionado en la póliza de seguro.

Texas Liability Insurance Card Tarjeta de Seguro de Responsabilidad Civil de Texas

Keep this card Guarde esta tarjeta
IMPORTANT: This card or a copy of your insurance policy IMPORTANTE: Usted debe mostrar esta tarjeta o una
must be shown when you apply for or renew your: copia de su póliza de seguro cuando solicite o renueve su:

• motor vehicle registration • registro del vehiculo motorizado

• driver's license • licencia para conducir

• motor vehicle safety inspection sticker • etiqueta de inspeccion de segurida para su vehiculo

You may also be asked to show this card or your policy if you También se puede pedir que usted muestre esta tarjeta o su
have an accident or if a peace officer asks to see it. póliza si tiene un accidente o si se la pide un oficial de policía.

All drivers in Texas must carry liability insurance on their Todos los conductores en Texas deben tener un seguro de
vehicles or otherwise meet legal requirements for financial responsabilidad civil para sus vehículos, o de lo contrario
responsibility. If you do not meet your financial deben cumplir con los requisitos legales de responsabilidad
responsibility requirements, you could be fined up to financiera. Si usted no cumple con los requisitos de
$1,000, your driver's license and motor vehicle registration responsabilidad financiera, podría estar sujeto a pagar una
could be suspended, and your vehicle could be impounded multa de hasta $1,000, mas la suspensión de su licencia de
for up to 180 days (at a cost of $15 per day). 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.

WARNING: A NAMED DRIVER POLICY DOES NOT ADVERTENCIA: UN CONDUCTOR MENCIONADO EN

PROVIDE COVERAGE FOR INDIVIDUALS RESIDING LA PÓLIZA NO PROVEE COBERTURA A LAS
IN THE INSURED'S HOUSEHOLD THAT ARE NOT PERSONAS QUE RESIDEN EN EL HOGAR DEL
NAMED ON THE POLICY. ASEGURADO QUE NO SON MENCIONADAS EN LA
PÓLIZA DE SEGUROS.