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CALIFORNIA SPECIAL CALIFORNIA RSVP Infinity Insurance caller P.O. Box 830189 Birmingham, AL 35283-0189 / 1-800-782-1020 AUTO APPLICATION X polity NUMBER: 104630359764001 interlingual rendition: 8.03 12/15/2011 applicator destination Name: speak to: HERMUS SARMAS 8915 judicatory Dr PRODUCER learning maker Code: 10463-26591 Name: cut across: metropolis/State/ hotfoot: anticipate: Ben Miller Insurance business office Inc 6400 ribbon CANYON BLVD STE 125 N HOLLYWOOD CA 916061570 818-587-2400 urban center/State/Zip: Jamestown, CA 95327 Home Phone: 209-883-0324 SSN: service department Information X Same as Mailing Address Garaging Address: 8915 Bench Dr Work Phone: Fax: 818-587-2401 urban center/State/Zip: Jamestown CA 95327 GENERAL INFORMATION terminal figure design typeface EFFECTIVE DATE EFFECTIVE beat termination DATE EXPIRATION TIME 6 MONTHS RSVP 04/13/2012 14:21:15 10/13/2012 12:01:00 AM number one wood(S) A ND/OR RESIDENT(S) OF HOUSEHOLD INFORMATION DRV NO DRIVER/RESIDENT RELATION TO applicator DATE OF nascency sexual activity MARITAL STATUS All persons age 15 and older, crystalize OR NOT, who reside with the applicant, and any other drivers of the vehicle(s) on this application.

LIVES WITH APPLICANT SR22 REQUIRED SR22 CASE NO 1 HERMUS SARMAS Self 06/13/1984 M Single Yes No DRIVER(S) AND/OR RESIDENT(S) OF HOUSEHOLD INFORMATION (continued) DRV NO DRIVER/RESIDENT DRIVERS LICENSE NUMBER father MONTHS EXPERIENCE DRIVING CURRENT VALID LICENSE front STATE DRV. LIC. NUM. POINTS 1 HERMUS SAR MAS D4538536 142 CA N/A 0 ! misfortune INFORMATION All accidents chargeable or not for the past 60 months must be shown. A chargeable accident is one where a person is 51% or more responsible and results in the injured partys end or damages exceeding a threshold of $1000.00 for occurrences on or after 12/11/11 or $750.00 for occurrences prior(prenominal) to 12/11/11. STATE OR DOES perfect bar DRV DATE OF DESCRIPTION OF ACCIDENT IS ACCIDENT TYPE OF ACCIDENT JURISDICTION WHERE OF DAMAGE EXCEED NO...If you want to establish a full essay, order it on our website: OrderCustomPaper.com

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