Interinsurance Exchange of the Automobile Club

Automobile Insurance Coverages and Limits

NAMED INSURED MEMBERSHIP NUMBER POLICY NUMBER
Ranzoor, Ali Ahmad 73087091 CAA184410864

A. APPLICATION INFORMATION:
APPLICANT’S NAME AND MAILING ADDRESS: APPLICANT’S RESIDENCE ADDRESS, IF DIFFERENT:
Ranzoor, Ali Ahmad
25625 Narbonne Ave APT 39
Lomita CA 90717
B. DRIVER INFORMATION: In addition to yourself, list all permit and licensed drivers in your household, including relatives, roommates, residence
employees, etc. Next, list all drivers who have regular access to your vehicles who DO NOT live with you, such as relatives, students away at school,
friends and household help.
Year First Relationship to Household
Drivers’ Names (Last, First) Excluded Date of Birth Licensed Applicant Resident
Ranzoor, Ali Ahmad No 01-10-1993 2011 Policy Holder Yes
Ali, Abida Yes 12-30-1999 Spouse Yes

C. VEHICLE INFORMATION: All vehicles to be insured.

Veh. Annual Odometer Deductibles Car Rental Expense
No. Year Make/Model Miles Reading Verified Mileage Salvage Comp. Collision (Limit Per Day)
11 2009
2016 BMW X5 4D
FORD/FUSION 4D [Link]
2WD, SE 15,000
10484 234,000
112539 AAAVerified
OnBoard Yes
No $1,000 $1,000 $45 a day

D. VEHICLE EQUIPMENT (if applicable): Coverage may not be provided for any special equipment unless equipment is listed below.

Vehicle No. Equipment Description Total Value

E. REQUESTED COVERAGES, LIMITS AND PREMIUMS: Coverage is not afforded unless a premium is shown.
Coverages Limits ($) Vehicle
Vehicle11 Vehicle 2 Vehicle 3
15,000 (each person)
Bodily Injury
(each occurrence)
373
30,000
Property Damage 5,000 (each occurrence) 337
Medical Payments (each person)

Excess Medical Payments (each person)

Uninsured and Underinsured Motorist Bodily Injury (each person)

(each accident)
Uninsured Collision

Uninsured Deductible Waiver

Comprehensive (Comp.) (See Deductibles Above)
Collision (See Deductibles Above)
Car Rental Expense (See Above)

ANNUAL VEHICLE PREMIUM: 710

LIMIT OF LIABILITY (IF APPLICABLE) / TRAILERS, MOTORHOMES, CLASSIC VEHICLES:

Vehicle No. Year Make/Model Purchase Price (Cost New) Limit of Liability

F. YOUR ANNUAL PREMIUM INCLUDES THE FOLLOWING DISCOUNTS: Please review these carefully, as you are warranting that you are entitled to
the following discounts.
Grp-Deg. Verified
Good Driver Good Student Student Away Multi - Vehicle Multi - Policy Mature Driver Driving Course Loyalty
Professional Mileage
Yes No No No No No No No No Yes

12-MONTH POLICY PREMIUM TOTAL: 710

Electronically Signed 2022-12-15 [Link] UTC - [Link]

Ali Ahmad Ranzoor 2022-12-15 [Link] (UTC-08:00)

X Nintex AssureSign®

Applicant’s Signature
778ac914-c730-472b-a61b-af6c0184a30b

Date Time
a.m. p.m.

X Co-Applicant’s Signature Date Time

a.m. p.m.

31195 1/19 Insurance provided to qualified Auto Club members by the Interinsurance Exchange of the Automobile Club. Pg. of 1
 INTERINSURANCE EXCHANGE of the Automobile Club
EXCLUSION OF DESIGNATED PERSON ENDORSEMENT

WARNING: READ THIS ENDORSEMENT CAREFULLY!

By signing this endorsement, no coverage will be provided by this policy while any vehicle is being operated by
any Designated Person listed below. Please read the following information in its entirety and make sure you
understand the exclusion of coverage before signing.

12/18/2022
Effective ________________________________12:01 A.M. Pacific Standard Time
CAA184410864
Forming a part of Policy No. ___________________________
issued by the INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB.
Ranzoor, Ali Ahmad
Named Insured: _____________________________________
Designated Person(s):
______________________________________________
Ali, Abida ______________________________________________

______________________________________________ ______________________________________________

______________________________________________ ______________________________________________

______________________________________________ ______________________________________________

We will issue or continue this policy because you and we have agreed that coverage afforded by Part I (Liability), Part II
(Expenses for Medical Services), Part III (Physical Damage) and Part IV (Uninsured Motorist) of this policy for the use of or
damage to any automobile insured shall not apply nor accrue to the benefit of you, any other person insured or any third party
claimant while said automobile is being operated by a designated person.
Under Part I (Liability), our obligation to defend shall not apply nor accrue to the benefit of you, any other person insured or
any third party while any automobile is being operated by a designated person. We will defend you when all of the following
apply to such designated person:
1. The designated person is a resident of the same household in which you reside.
2. As a result of operating your insured automobile, the designated person is jointly sued with you.
3. The designated person is an insured under a separate automobile liability policy issued to the designated person as a
named insured, which does not provide a defense to you.
This agreement will be in force as long as your policy remains in force and shall apply to any continuation, renewal or
replacement of your policy by you or to reinstatement of your policy within 30 days of any lapse thereof.
When uninsured motorist coverage—bodily injury (Coverage F) is deleted with respect to one or more natural persons
designated by name when operating a motor vehicle, California law requires the agreement to be in the following form:
“The California Insurance Code requires an insurer to provide uninsured motorist coverage in each bodily injury liability
insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those
provisions also permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a
motor vehicle is operated by a natural person or persons designated by name. Uninsured motorists coverage insures the
insured, his or her heirs, or legal representatives for all sums within the limits established by law, which the person or
persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death, to
the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident
of the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p)
of Section 11580.2 of the Insurance Code*.”
*Subdivision (p) of Section 11580.2 of the Insurance Code defines an underinsured motor vehicle as one that is insured
under a motor vehicle liability policy, or automobile liability insurance policy, self-insured, or for which a cash deposit or
bond has been posted to satisfy a financial responsibility law, but insured for an amount that is less than the uninsured
motorist limits carried on the motor vehicle of the injured person.
All provisions of your policy not affected by this endorsement remain unchanged.
By accepting this endorsement you declare that you have read the endorsement and understand it, that it represents a
voluntary agreement between you and us, and that you agree to be bound by the limitations it imposes.
Electronically Signed 2022-12-15 [Link] UTC - [Link]

Ali Ahmad Ranzoor

Nintex AssureSign® 27d35775-cb29-465a-89b3-af6c0184a315 2022-12-15 [Link] (UTC-08:00)
Accepted ____________________________________________________________________________________________
Signature of Insured Date Hour
Ali Ahmad Ranzoor
Print Name Here
ACSC Management Services, Inc.
ATTORNEY-IN-FACT
2184
Ed. 4-17
 INTERINSURANCE EXCHANGE of the Automobile Club

DELETION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE ENDORSEMENT

(BODILY INJURY)

Effective 12/18/2022 12:01 A.M. Pacific Standard Time

Forming a part of Policy No. CAA184410864 issued by the INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB.

You have the option of purchasing uninsured and underinsured motorist coverage limits equal to your bodily injury liability
coverage limits. You also have the option of selecting lower limits or deleting the coverage completely. The limits available for
selection are listed below.
$15,000 / $30,000 $50,000 / $100,000 $250,000 / $500,000
$20,000 / $40,000 $100,000 / $200,000 $500,000 / $500,000
$25,000 / $50,000 $100,000 / $300,000 $500,000 / $1,000,000
$30,000 / $60,000 $300,000 / $300,000 $1,000,000 / $1,000,000

HOWEVER, YOU HAVE DECIDED AND WE HAVE AGREED TO COMPLETELY DELETE UNINSURED AND
UNDERINSURED MOTORIST COVERAGE-BODILY INJURY (COVERAGE F) FROM YOUR POLICY.

California law requires the agreement to be in the following form:

"The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability
insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those
provisions also permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a
motor vehicle is operated by a natural person or persons designated by name. Uninsured motorists coverage insures the
insured, his or her heirs, or legal representatives for all sums within the limits established by law, that the person or
persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death, to
the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of
the same household. An uninsured motor vehicle includes an underinsured motor vehicle as defined in subdivision (p) of
Section 11580.2 of the Insurance Code*."
*Subdivision (p) of Section 11580.2 of the Insurance Code defines an underinsured motor vehicle as one that is insured
under a motor vehicle liability policy, or automobile liability insurance policy, self-insured, or for which a cash deposit or
bond has been posted to satisfy a financial responsibility law, but insured for an amount that is less than the uninsured
motorist limits carried on the motor vehicle of the injured person.
This agreement will be in force as long as your policy remains in force and shall apply to any continuation, renewal or
replacement of your policy by you or to reinstatement of your policy within 30 days of any lapse thereof.
All provisions of your policy not affected by this endorsement remain unchanged.
By accepting this endorsement you declare that you have read the endorsement and understand it, that it represents a
voluntary agreement between you and us and that you agree to be bound by the limitations it imposes.

Electronically Signed 2022-12-15 [Link] UTC - [Link]

Ali Ahmad Ranzoor

Nintex AssureSign® bc8b45c1-a355-4a68-94fd-af6c0184a328
2022-12-15 [Link] (UTC-08:00)
Accepted _________________________________________________________________________________________
Signature of Insured Date Hour

ACSC Management Services, Inc.

ATTORNEY- IN-FACT

2297
E 8-09
 Interinsurance Exchange of the Automobile Club
Automobile Insurance Application
NAMED INSURED MEMBERSHIP NUMBER POLICY NUMBER
Ranzoor, Ali Ahmad 004-73087091 CAA184410864
1. ADDITIONAL APPLICANT INFORMATION: Do You Own Any Vehicles That You Do Not Want To Insure With Us Now? YES NO
2. NON-DRIVER HOUSEHOLD RESIDENT INFORMATION: List ALL residents of your household who are NOT drivers. For each, give their reason for
not driving. (For example, “child,” “never learned,” “license suspended,” “disabled,” etc.)
Name All Other Residents (Last Name, First Name M.I.) Gender Date of Birth Relationship To Applicant Reason For Not Driving
Dependent Child
Ali Zuhra F 02-08-2018
Dependent Child
Ali Zaneera F 02-03-2019
3. POLICY PERIOD: (Pacific Standard Time) 12-MONTH POLICY PREMIUM TOTAL: $ 710
FROM: Month December Day 18 Year 2022 12:01 A.M. TO: Month December Day 18 Year 2023 12:01 A.M.
If the “FROM” date above has not been filled in, when do you want your policy to become effective? Month Day Year

IMPORTANT INFORMATION AND BINDER OF INSURANCE:

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REWDLQRUDPHQGLQVXUDQFHFRYHUDJHRUWRPDNHDFODLPIRUWKHSD\PHQWRIDORVVLVJXLOW\RIDFULPHDQGPD\EHVXEMHFWWRILQHVDQGFRQILQHPHQWLQVWDWH
SULVRQ
,WLV\RXUUHVSRQVLELOLW\WRFKRRVHWKHOHYHORILQVXUDQFHSURWHFWLRQWKDWEHVWVXLWV\RXUQHHGVE\VHOHFWLQJDQGPDLQWDLQLQJFRYHUDJHVDQGOLPLWVWKDWZLOODGHTXDWHO\
SURWHFW\RXDQG\RXUSURSHUW\LQWKHHYHQWRIDORVV
:KLOHZHUHYLHZ\RXUDSSOLFDWLRQIRULQVXUDQFHFRYHUDJHLVERXQGHIIHFWLYHDW$03DFLILF6WDQGDUG7LPHRQWKHGDWHUHTXHVWHGDERYH%87127($5/,(5
7+$1WKHIROORZLQJGDWH
- IF YOU PAID YOUR PREMIUM DEPOSIT BY CREDIT CARD OR ELECTRONIC FUNDS TRANSFER, OR IN PERSON BY CASH OR CHECK: Coverage is
bound no earlier than the day after the date you paid your premium deposit.
- IF YOU PAID YOUR PREMIUM DEPOSIT BY CHECK VIA MAIL: Coverage is bound no earlier than the day after the postmark date on the envelope in
which your premium deposit and signed application are mailed to us. If you do not enclose your premium deposit with the signed application, coverage does
not become effective until after your application is approved by us and your payment is received.
This binder will expire 60 days after its effective date or may be cancelled by the named insured at any time during this 60 day period. Approval of the application and
issuance of a policy to you will void the binder. We may cancel this binder by mailing to the named insured at the address shown on the application at least 10 days’
advance written notice of cancellation. Unless a policy is issued, a premium charge will be made for coverage provided under this binder. This binder provides the
coverages and limits shown in this application and its enclosures, on the terms described in the applicable policy form and endorsements. This binder does not
provide cumulative insurance with any existing policy.
Comprehensive and Collision coverages may be severely restricted, suspended or revoked unless vehicles requiring inspection for physical damage coverage are
inspected by an authorized inspector no later than seven days after the policy effective date.
Notice of Short Rate Cancellation: Any cancellation of your entire automobile policy requested by you during the first policy period, including cancellation for
nonpayment of premium, will be calculated on a short rate basis. This means the amount due us for the time your policy was actually in effect will be more than a
proportionate share of the annual premium. The additional amount will not exceed 11% of the annual premium.
I have read, agree and subscribe to the subscriber’s agreement of the Interinsurance Exchange of the Automobile Club and to all other statements, notices, terms,
conditions and agreements appearing on all pages of this application, including all attachments and other documents provided with this application. I declare that all
statements I have made are true and that I have fully disclosed all required information. I understand that my insurance policy will be issued in reliance on the
information I provided, including information about my household, its vehicles and their drivers, and that such information will be used to determine my eligibility for
insurance and premium. I also understand that inaccurate or incomplete information may jeopardize my coverage or change my premium.
To the extent my authorization is required under applicable law, for a period of one year from the date I sign, I authorize the Automobile Club of So. California and the
Interinsurance Exchange of the Automobile Club and their employees and agents (Authorized Parties) to verify the accuracy of the information I have provided using
other available sources and to access personal and confidential information concerning me and other drivers. I hereby waive Cal. Veh. Code § 1808.21 to allow the
Authorized Parties to access confidential information (including residence address) concerning me and other drivers in Department of Motor Vehicles records.
I request issuance of a policy with the coverages and limits described in the accompanying Automobile Insurance Coverages and Limits form.

X Applicant’s Signature Date Time

a.m. p.m.

X Co-Applicant’s Signature Date Time

a.m. p.m.

a.m. p.m.
Representative’s Signature Date Time

Electronically Signed 2022-12-15 [Link] UTC - [Link]

2022-12-15 [Link] (UTC-08:00)

Ali Ahmad Ranzoor Nintex AssureSign® 2e393665-023c-4eb6-8348-af6c0184a331

30551 1/ Insurance provided to qualified Auto Club members by the Interinsurance Exchange of the Automobile Club. Pg.  of 2
 Interinsurance Exchange of the Automobile Club
Automobile Insurance Application
NAMED INSURED MEMBERSHIP NUMBER POLICY NUMBER
Ranzoor, Ali Ahmad 004-73087091 CAA184410864
1. ADDITIONAL APPLICANT INFORMATION: Do You Own Any Vehicles That You Do Not Want To Insure With Us Now? YES NO
2. NON-DRIVER HOUSEHOLD RESIDENT INFORMATION: List ALL residents of your household who are NOT drivers. For each, give their reason for
not driving. (For example, “child,” “never learned,” “license suspended,” “disabled,” etc.)
Name All Other Residents (Last Name, First Name M.I.) Gender Date of Birth Relationship To Applicant Reason For Not Driving
Dependent Child
Ali Sudais Ahmad M 03-13-2020

3. POLICY PERIOD: (Pacific Standard Time) 12-MONTH POLICY PREMIUM TOTAL: $ 710
FROM: Month December Day 18 Year 2022 12:01 A.M. TO: Month December Day 18 Year 2023 12:01 A.M.
If the “FROM” date above has not been filled in, when do you want your policy to become effective? Month Day Year

IMPORTANT INFORMATION AND BINDER OF INSURANCE:

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REWDLQRUDPHQGLQVXUDQFHFRYHUDJHRUWRPDNHDFODLPIRUWKHSD\PHQWRIDORVVLVJXLOW\RIDFULPHDQGPD\EHVXEMHFWWRILQHVDQGFRQILQHPHQWLQVWDWH
SULVRQ
,WLV\RXUUHVSRQVLELOLW\WRFKRRVHWKHOHYHORILQVXUDQFHSURWHFWLRQWKDWEHVWVXLWV\RXUQHHGVE\VHOHFWLQJDQGPDLQWDLQLQJFRYHUDJHVDQGOLPLWVWKDWZLOODGHTXDWHO\
SURWHFW\RXDQG\RXUSURSHUW\LQWKHHYHQWRIDORVV
:KLOHZHUHYLHZ\RXUDSSOLFDWLRQIRULQVXUDQFHFRYHUDJHLVERXQGHIIHFWLYHDW$03DFLILF6WDQGDUG7LPHRQWKHGDWHUHTXHVWHGDERYH%87127($5/,(5
7+$1WKHIROORZLQJGDWH
- IF YOU PAID YOUR PREMIUM DEPOSIT BY CREDIT CARD OR ELECTRONIC FUNDS TRANSFER, OR IN PERSON BY CASH OR CHECK: Coverage is
bound no earlier than the day after the date you paid your premium deposit.
- IF YOU PAID YOUR PREMIUM DEPOSIT BY CHECK VIA MAIL: Coverage is bound no earlier than the day after the postmark date on the envelope in
which your premium deposit and signed application are mailed to us. If you do not enclose your premium deposit with the signed application, coverage does
not become effective until after your application is approved by us and your payment is received.
This binder will expire 60 days after its effective date or may be cancelled by the named insured at any time during this 60 day period. Approval of the application and
issuance of a policy to you will void the binder. We may cancel this binder by mailing to the named insured at the address shown on the application at least 10 days’
advance written notice of cancellation. Unless a policy is issued, a premium charge will be made for coverage provided under this binder. This binder provides the
coverages and limits shown in this application and its enclosures, on the terms described in the applicable policy form and endorsements. This binder does not
provide cumulative insurance with any existing policy.
Comprehensive and Collision coverages may be severely restricted, suspended or revoked unless vehicles requiring inspection for physical damage coverage are
inspected by an authorized inspector no later than seven days after the policy effective date.
Notice of Short Rate Cancellation: Any cancellation of your entire automobile policy requested by you during the first policy period, including cancellation for
nonpayment of premium, will be calculated on a short rate basis. This means the amount due us for the time your policy was actually in effect will be more than a
proportionate share of the annual premium. The additional amount will not exceed 11% of the annual premium.
I have read, agree and subscribe to the subscriber’s agreement of the Interinsurance Exchange of the Automobile Club and to all other statements, notices, terms,
conditions and agreements appearing on all pages of this application, including all attachments and other documents provided with this application. I declare that all
statements I have made are true and that I have fully disclosed all required information. I understand that my insurance policy will be issued in reliance on the
information I provided, including information about my household, its vehicles and their drivers, and that such information will be used to determine my eligibility for
insurance and premium. I also understand that inaccurate or incomplete information may jeopardize my coverage or change my premium.
To the extent my authorization is required under applicable law, for a period of one year from the date I sign, I authorize the Automobile Club of So. California and the
Interinsurance Exchange of the Automobile Club and their employees and agents (Authorized Parties) to verify the accuracy of the information I have provided using
other available sources and to access personal and confidential information concerning me and other drivers. I hereby waive Cal. Veh. Code § 1808.21 to allow the
Authorized Parties to access confidential information (including residence address) concerning me and other drivers in Department of Motor Vehicles records.
I request issuance of a policy with the coverages and limits described in the accompanying Automobile Insurance Coverages and Limits form.
Electronically Signed 2022-12-15 [Link] UTC - [Link]

2022-12-15 [Link] (UTC-08:00)

X Applicant’s Signature
Ali Ahmad Ranzoor Nintex AssureSign® ba6c8747-40cd-44b5-8739-af6c0184a33a

Date Time
a.m. p.m.

X Co-Applicant’s Signature Date Time

a.m. p.m.

a.m. p.m.
Representative’s Signature Date Time

30551 1/ Insurance provided to qualified Auto Club members by the Interinsurance Exchange of the Automobile Club. Pg.  of 2
 Interinsurance Exchange of the Automobile Club


Ranzoor, Ali Ahmad
Policy Number: CAA184410864

25625 Narbonne Ave APT 39

Lomita CA 90717


SUBSCRIBER’S AGREEMENT
The Interinsurance Exchange of the Automobile Club is organized under the California Insurance Code as a “reciprocal”
or “interinsurance exchange.” In such an organization, the persons insured, known as ”subscribers,” exchange contracts
of insurance with one another. As permitted by law, the Exchange uses a corporate attorney-in-fact, ACSC Management
Services, Inc. to execute these insurance contracts. California law requires that each subscriber sign a power of attorney
authorizing the attorney-in-fact to act on the subscriber’s behalf. Therefore, in order for you to be insured by the
Exchange and in order for us to conduct business on your behalf, you must sign a Subscriber’s Agreement. It is
applicable to all insurance policies you have now or will have with the Exchange.
Subscriber’s Agreement
As a subscriber of the Interinsurance Exchange of the Automobile Club (“the Exchange”), I hereby agree as follows:
1. I appoint ACSC Management Services, Inc. (“Management Services”), a California corporation, as my attorney-in-fact
and authorize it to act on my behalf under this power of attorney for the following purposes:
To exchange with other subscribers of the Exchange insurance contracts providing insurance against any loss
which may be insured against under the laws of the State of California. My attorney-in-fact is authorized to sign
and deliver all necessary contracts and to perform all other related acts that subscribers may perform.
2. Management Services has the right and power to appoint a substitute attorney-in-fact and to revoke such appointment.
3. Management Services shall maintain its principal office at 2601 S. Figueroa Street, Los Angeles, California, 90007-3294.
4. Management Services shall exercise this power of attorney in accordance with the Rules and Regulations of the Board
of Governors of the Exchange and the provisions of the Certificate of Authority issued by the Insurance Commissioner
of the State of California.
5. All other rights reserved to subscribers, including the right of supervision and delegation of duties to the attorney-in-
fact, shall be exercised on my behalf by the Board of Governors of the Exchange. This Board shall be composed of
persons who are members of the Board of Directors of the Automobile Club of Southern California, and the members
of this Board shall be appointed by the Board of Directors of the Automobile Club of Southern California. I agree to be
bound by the bylaws and the Rules and Regulations adopted by the Board of Governors and any modifications that
may be made to them. The Bylaws and the Rules and Regulations and any modifications to them shall be on file in the
principal office of the Exchange and the principal office of the Automobile Club of Southern California.
6. No present or future subscriber of the Exchange shall be liable in excess of the amount of his or her premium for any
portion of the debts or liabilities of the Exchange. Policyholder’s dividends or credits may be returned to the subscriber
by resolution of the Board of Governors.

ACSC Management Services, Inc.

ATTORNEY-IN-FACT

Electronically Signed 2022-12-15 [Link] UTC - [Link]

Ali Ahmad Ranzoor

Nintex AssureSign® b98c87b3-b178-469a-b93c-af6c0184a343
2022-12-15 [Link] (UTC-08:00)

8216
Ed. 01-07
 VEHICLES ON POLICY
PROOF OF INSURANCE
YEAR MAKE VEH I.D. #
Interinsurance Exchange of the Automobile Club
2016 FORD 3FA6P0H71GR384989
NAIC #: 15598
Named Insured Policy Number: CAA184410864

--- FOLD HERE ---

Ranzoor, Ali Ahmad DRIVERS ON POLICY
Ranzoor, Ali Ahmad

Effective Date: 12/18/2022 Expiration Date: 12/18/2023

This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified vehicles
and named insureds. Coverage subject to policy terms and limits.

IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAIMS HOTLINE 1-800-672-5246
After an accident, exchange information with the other party and
follow these 5 easy steps:

--- FOLD HERE ---

Step 1: Pull vehicle over to a safe place. Get the names, Step 4: Take photos of the vehicles involved, damages and
addresses, and phone numbers of all persons involved in the surrounding area of the accident, if it is safe to do so.
accident, e.g., pedestrians, witnesses, other passengers, etc.
Step 5: Call our AAA Claims Hotline at 800-672-5246 to report
the loss. If necessary, we will arrange to have your vehicle towed.
Step 2: Take photos of or write down the other person’s
Our provider’s tow trucks always display the AAA emblem.
driver’s license information and other vehicle’s license plate
number, including state of registration. Do not admit responsibility for or discuss the circumstances of the accident
with anyone other than the police or an authorized Auto Club claims
Step 3: Take photos of or write down the other person’s representative. Do not disclose your policy limits to anyone.
insurance card information.
For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p.m. or Saturday from 8 a.m. to 5 p.m.

Place a Proof of Insurance card in each vehicle insured under your policy. In
addition, we suggest that each listed driver carry a card. Under California law, Call our AAA Claims Hotline at
drivers and owners of a motor vehicle must be able to show proof of financial 1-800-672-5246
responsibility at all times. These cards become invalid and should be destroyed
on the expiration or termination date of the policy.
VEHICLES ON POLICY
PROOF OF INSURANCE
YEAR MAKE VEH I.D. #
Interinsurance Exchange of the Automobile Club
2016 FORD 3FA6P0H71GR384989
NAIC #: 15598
Named Insured Policy Number: CAA184410864
--- FOLD HERE ---

Ranzoor, Ali Ahmad DRIVERS ON POLICY

Ranzoor, Ali Ahmad

Effective Date: 12/18/2022 Expiration Date: 12/18/2023

This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified vehicles
and named insureds. Coverage subject to policy terms and limits.

IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAIMS HOTLINE 1-800-672-5246
After an accident, exchange information with the other party and
follow these 5 easy steps:
--- FOLD HERE ---

Step 1: Pull vehicle over to a safe place. Get the names, Step 4: Take photos of the vehicles involved, damages and
addresses, and phone numbers of all persons involved in the surrounding area of the accident, if it is safe to do so.
accident, e.g., pedestrians, witnesses, other passengers, etc.
Step 5: Call our AAA Claims Hotline at 800-672-5246 to report
the loss. If necessary, we will arrange to have your vehicle towed.
Step 2: Take photos of or write down the other person’s
Our provider’s tow trucks always display the AAA emblem.
driver’s license information and other vehicle’s license plate
number, including state of registration. Do not admit responsibility for or discuss the circumstances of the accident
with anyone other than the police or an authorized Auto Club claims
Step 3: Take photos of or write down the other person’s representative. Do not disclose your policy limits to anyone.
insurance card information.
For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p.m. or Saturday from 8 a.m. to 5 p.m.

8165 12/20
AAA Auto Pay Plan for Debit Card
Terms and Conditions for Insurance and Membership
The Authorization Agreement at the bottom of this page is valid only for insurance policies written by the issuer of the insurance policies identified
below (“Insurer”) and for your membership with the AAA club that issued the membership identified below in the Authorization Agreement (“AAA”).*
Insurance only: Automatic charges to your debit card for insurance policies will begin with the first AAA Auto Pay Plan payment billed after the
Authorization Agreement is received and processed (Please allow 15 days for processing). Until then, your insurance payment is still due on the date
shown on your most recent billing statement and should be returned to us in the white envelope provided. Once AAA Auto Pay is active, your
periodic billing statements will indicate the amount and timing of the next payment prior to your card being charged for that payment. We gave you
notice of the amount of all applicable fees at the time you applied for the insurance policy(ies) below and upon renewals of your policy(ies).
Installment payment plans and all fees are subject to change without notice. AAA Auto Pay automatic payments are subject to all applicable
installment and other fees.
Membership only: At least one month before your AAA membership expires, we’ll send a statement of your current services and renewal dues
amount. We will automatically renew your membership and charge the dues shown on your debit card 10-15 days before the renewal date, unless
you contact us to make a change to or cancel AAA Auto Pay.
Policyholders and members who have payments returned unpaid or otherwise rejected from their financial institution may have the AAA Auto Pay
Plan authorization revoked as to all insurance policies by Insurer and as to AAA membership by AAA. In the event that this occurs, you will be
notified by mail and a return payment fee and late fee may be added to your bill (or to a second attempted debit to your account). If insurance AAA
Auto Pay is revoked, installments remaining for the current insurance policy period will be billed on your regular payment plan with statements
mailed to you and outstanding membership dues and fees will be billed with statements mailed to you periodically.
If an error is made, you give the Insurer and AAA permission to correct it by initiating debits to your debit card on file.
You may revoke enrollment in the AAA Auto Pay Plan as to any one or more insurance policies and/or your membership at any time by completing a
revocation form at [Link]/form or upon request by contacting us at 1.800.924.6141 or your local AAA branch.
If your VISA, MasterCard, or Discover debit card issuing bank participates in the Card Account Updater program, we may receive an updated debit
card account number and/or expiration date for the card information you have previously provided us, unless you Opt Out of the service with your
issuing bank. We will update our files and use the new information when we bill you under the AAA Auto Pay program. We won't receive updated
information if your account has been closed. Debit card available with VISA, Mastercard or Discover only.
* If you would like to make payments with more than one debit card, you will need to complete one Authorization Agreement for each card. If you
would like to enroll more than three insurance policies in AAA Auto Pay, please use one Authorization Agreement for every three policies.

To have your insurance premiums or membership dues automatically charged to your debit card each year,
Complete and mail the form below using the envelope provided or return to:

AAA
P.O. Box 25499 OR Fax: 714.850.8097
Santa Ana, CA 92799-5499
Important: We must have a signature to complete this transaction. Please do not return by e-mail.

Please keep a copy of this form for your records.

Please detach at line.

AUTHORIZATION AGREEMENT FOR INSURANCE DEBIT CARD PAYMENTS

AAA Auto Pay Plan
 To use AAA Auto Pay for your membership, enter your Club Code and Membership Number as it appears on your membership card in the boxes below.
 Please enter the number of each insurance policy you want billed through AAA Auto Pay.
 Unless the last 4 digits of your debit card (previously provided to us) have already been filled in, please enter your complete 16-digit account
number and card expiration date below.
Club Code First 8 Digits of Membership Number Letter Prefix (up to 3)

MEMBER # - POLICY # C A A 1 8 4 4 1 0 8 6 4
Letter Prefix (up to 3) Letter Prefix (up to 3)

POLICY # POLICY # l

I hereby authorize the Interinsurance Exchange of the Automobile Club (“Exchange”) and Automobile Club of Southern California (“AAA”) to charge my
DEBIT CARD ACCOUNT indicated below for (i) all amounts that become due by me to the Exchange, including, without limitation, insurance premiums
on the above policies and any renewals thereof, finance charges, installment, return payment, late payment and other fees, and (ii) all membership dues
that become due by me to AAA. All charges to my Debit account are governed by the Terms and Conditions that accompanied this Agreement.

MasterCard® EXPIRE
Visa® CARD # x x x x x x x x x x x x 0 3 5 9 DATE 0 9 / 2 7
Discover® MM YY

This authorization is to remain in full force and effect until terminated by the Exchange or AAA or until the Exchange or AAA has received notification from
me of its termination in such time and in such manner as to afford the Exchange or AAA, as applicable, a reasonable opportunity to act on it.
Electronically Signed 2022-12-15 [Link] UTC - [Link]

Ali Ahmad Ranzoor

2022-12-15 [Link] (UTC-08:00) Nintex AssureSign® dbc5a73d-aaf7-4a8d-97e2-af6c0184a352

NAME OF ACCOUNT HOLDER DATE SIGNATURE OF ACCOUNT HOLDER

E702538 004-73087091 Ali Ahmad Ranzoor
AAA Employee # (if applicable) Branch/Sec # Membership # Member Name
** Sensitive Regulated Data ** 8684 02/14