INSTRUCTIONS

Policy Number Insured Name Date

BGT40026546

FERNANDO DELGADO

06-29-2013

DO NOT SEND REQUEST FOR THIS ENDORSEMENT NOR COPY OF PRINTED ENDORSEMENT TO NEWPORT GENERAL AGENCY. Step 1: Ensure that the following items have printed: Endorsement ID Card(s) Give the insured their copy of the: Endorsement ID Card(s) Retain a copy of the following for your records: Endorsement
Next installment payment of approximately $43.43 is due by 06/27/2013.

Step 2:

Step 3:

There are 05 installments remaining.

Installment amounts were figured based on amount of endorsement down receipted. If payment already submitted for the installment due date shown, pay the difference in amount shown and amount already submitted. A $5 late fee will be applicable if the payment is postmarked after the due date. POLICY PENDING CANCELLATION FOR NON PAY EFFECTIVE 07-08-2013 AND WILL NOT BE REINSTATED UNLESS ITEM(S) REQUIRED FOR REINSTATEMENT WERE PROVIDED TO COMPANY PRIOR TO CANCELLATION EFFECTIVE DATE. BINDING THIS ENDORSEMENT AND RECEIPTING MONIES FOR IT DO NOT CONSTITUTE REINSTATEMENT.

INSTRCT_NEWPRT (2012/12)

Endorsement

NEWPORT GENERAL AGENCY

#19

PO BOX 601059, DALLAS, TX 75360-0000 Phone (866)563-9767 Fax (866)509-2329

Policy Number: BGT40026546 Company: OLD AMERICAN COUNTY MUTUAL FIRE Endorsement Effective Date: 06-29-2013 12:28:30 Policy Expiration Date: 12-07-2013 Insured:

INS CO PM CDT

Date & Time Processed: Created By: 188000 Producer:

06-29-2013

12:28:30 PM CDT

FERNANDO DELGADO 13631 TIMBER WEST LN CONROE, TX 77304-4717 Policy Change Summary

188000 EL FARO MULTISERVICES 1616 N FRAZIER ST STE D CONROE, TX 77301

Cancelled vehicle # 3 2000 DODGE NEON HIGHLINE/NEON ES 1B3ES46C4YD502718. Added vehicle # 5 1996 CHEVROLET PICKUP 1500 2GCEC19W4T1209440. ****POLICY PENDING CANCELLATION FOR NON PAY EFFECTIVE 07-08-2013 AND WILL NOT BE REINSTATED UNLESS ITEM(S) REQUIRED FOR REINSTATEMENT WERE PROVIDED TO COMPANY PRIOR TO CANCELLATION EFFECTIVE DATE. BINDING THIS ENDORSEMENT AND RECEIPTING MONIES FOR IT DO NOT CONSTITUTE REINSTATEMENT.

The Auto(s) or Trailer(s) described in this policy is principally garaged at the above address unless otherwise stated: DRIVERS Dvr Name Class Pts Dvr Name Class Pts

FERNANDO DELGADO

ER

DONNA MARIE BEATY

CN

This policy contains 1 excluded drivers.

COVERED AUTOS Auto Year Manufacturer Model VIN Terr Sym Drv
OWN SURCH BUS U

3 4 5

**** 1999 1996

Vehicle removed eff. 06-29-2013 MAZDA PROTEGE ES CHEVROLET PICKUP 1500

***************** JM1BJ2214X0146225 2GCEC19W4T1209440

LIENHOLDERS

** 40 40

** 12/12 10/10

** 2 1

W2 W2

Any loss under Part D is payable as interest may appear to the named insured and (include name and address)

Auto

Name

Address

City

State

Zip Code

COVERAGE Bodily Injury Liability Property Damage Liability Uninsured/Underinsured Motorists BI Uninsured/Underinsured Motorists PD
($250 Deductible Applicable to Property Damage Liability)

LIMITS
30,000 Each Person 60,000 Each Accident 25,000 Each Accident

NEW TERM PREMIUM

PREMIUM CHANGE

99.00 76.00

-4.00 -3.00

Each Person Each Accident Each Person Each Person Each Person

Personal Injury Protection Medical Payments

Coverage for Damage to your Auto Actual Cash Value unless otherwise Stated

Other Than Collision Collision Rental Reimbursement Towing & Labor

Less Deductible Less Deductible

Each Day: Maximum: Each Disablement:

Special Equipment Policy Wide Surcharges/Discounts:

Multi-Car Renewal

MC RN
Premium Due To Change:

-7.00

Form numbers for endorsements attached to policy: 515A, 551, OACM.CRIMEINTENT.008, OACM.PHYSDAM.001, OACM.YCA.002, OACM.AUTHDRIV.003A, OACM.STORAGE.004, OACM.DELFEE.005, OACM.CONTLIAB.006, OACM.AUTOTERM.007, OACM.CP.013B, OACM. OUTOFSTATE.016A, OACM.RENTPROP-NOAUTO.019 P/R Factor: 0.880

Insured Signature X________________________________

Producer Signature X________________________________

END_TX_SIG (2012/12)

ANY PREMIUM ADJUSTMENT WILL BE REFLECTED ON THE NEXT BILLING STATEMENT

Endorsement #19
Attachment Policy Number : BGT40026546 Insured Name : FERNANDO DELGADO EL FARO MULTISERVICES Producer : Policy Period : to 06-07-2013 12-07-2013

NEW 6 MO. PREMIUM: _____________________________________________________________________________________ VEH DEDUCTIBLE BI PD MP OTC COL UMBI UMPD PIP SE RENT TOW TOTAL 4 0/ 0 56 43 0 0 0 0 0 0 0 0 0 99 5 0/ 0 43 33 0 0 0 0 0 0 0 0 0 76 _____________________________________________________________________________________ TOTAL 99 76 0 0 0 0 0 0 0 0 0 175 PREMIUM CHANGE: VEH BI PD MP OTC COL UMBI UMPD PIP SE RENT TOW TOTAL 3 -51 -39 0 0 0 0 0 0 0 0 0 -90 4 9 7 0 0 0 0 0 0 0 0 0 16 5 38 29 0 0 0 0 0 0 0 0 0 67 _____________________________________________________________________________________ TOTAL -4 -3 0 0 0 0 0 0 0 0 0 -7

END-OF (2012/01)

515A - EXCLUSION OF NAMED DRIVERS & PARTIAL REJECTION OF COVERAGES

Policy Number :

BGT40026546

Insured Name :

FERNANDO DELGADO

This acknowledgement and rejection is applicable to all renewals issued by the Company or any affiliated insurer. You also agree that the insurance coverage afforded by this policy shall not apply while: Name: GUADALUPE FIGUEROA DOB: 12-12-1984 Relation: WIFE the EXCLUDED DRIVER(S) is operating your covered auto or any other motor vehicle. You further agree that this endorsement will also serve as a rejection of Uninsured / Underinsured Motorist Coverage and Personal Injury Protection Coverage while your covered auto or any other motor vehicle is operated by the excluded driver. I, the above named insured, do hereby state that if one of the above named excluded persons is my legal spouse, I agree and understand that by signing below, no coverage will be afforded under this policy to the above named excluded person (spouse).

All other terms and conditions remain unchanged. OLD AMERICAN COUNTY MUTUAL FIRE INS CO Issued on behalf of: Attached to and forming part of policy: BGT40026546 FERNANDO DELGADO Issued to: 06-07-2013 Policy Effective: 06-29-2013 Prepared: NEWPORT GENERAL AGENCY By:
ATTACH (2012/06)

Texas Liability Insurance Card

Keep this card IMPORTANT: This card or a copy of your insurance policy must be shown when you apply for or renew your: motor vehicle registration driver's license motor vehicle safety inspection sticker You also may be asked to show this card or your policy if you have an accident or if a peace officer asks to see it. All drivers in Texas must carry liability insurance on their vehicles or otherwise meet legal requirements for financial responsibility. Failure to do so could result in fines up to $1,000, suspension of your driver's license and motor vehicle registration, and impoundment of your vehicle for up to 180 days (at a cost of $15 per day).

Tarjeta de Seguro de Responsabilidad de Texas

Guarde esta tarjeta IMPORTANTE: Este tarjeta o una copia de su pliza de seguro debe ser mostrada cuando usted solicite o renueve su: registro de vehculo de motor licencia para conducir etiqueta de inspeccin de seguridad para su vehiculo Puede que usted tenga tambin que mostrar esta tarjeta o su pliza de seguro si tiene un accidente o si un oficial de la paz se la pide. Todos los conductores en Texas deben de tener seguro de responsabilidad para sus vehculos, o de otra manera llenar los requisitos legales de responsabilidad civil. Fallar en llenar este requisito pudiera resultar en multas de hasta $1,000, suspensin de su licencia para conducir y su registro de vehculo de motor, y la retencin de su vehiculo por un periodo de hasta 180 das (a un costo de $15 por da).

TEXAS LIABILITY INSURANCE CARD

THIS POLICY PROVIDES AT LEAST THE MINIMUM AMOUNTS OF LIABILITY INSURANCE REQUIRED BY THE TEXAS MOTOR VEHICLE SAFETY RESPONSIBILITY ACT FOR THE SPECIFIED VEHICLE AND NAMED INSUREDS AND MAY PROVIDE COVERAGE FOR OTHER PERSONS AND OTHER VEHICLES AS PROVIDED BY THE INSURANCE POLICY.
Insurance Company: To Report a Claim: For Claims Status: Agent/Producer:
OLD AMERICAN COUNTY MUTUAL FIRE INS CO (866)905-4461 (866)509-3509
1999 MAZDA 1996 CHEVROLET PROTEGE ES PICKUP 1500

(866) 563-9767
JM1BJ2214X0146225 2GCEC19W4T1209440

Vehicle Year Make Model VIN:

EL FARO MULTISERVICES 1616 N FRAZIER ST STE D CONROE, TX 77301 (936)539-5391

Policy Number: Effective Date: 06-29-2013 Named Insured:

BGT40026546

Expiration Date: 12-07-2013 Included Drivers: FERNANDO DELGADO DONNA MARIE BEATY

FERNANDO DELGADO 13631 TIMBER WEST LN CONROE, TX 77304

If any vehicle(s) or driver(s) listed above have changed, please contact your agent immediately.
ID_TX (2012/12)

Texas Liability Insurance Card

Keep this card IMPORTANT: This card or a copy of your insurance policy must be shown when you apply for or renew your: motor vehicle registration driver's license motor vehicle safety inspection sticker You also may be asked to show this card or your policy if you have an accident or if a peace officer asks to see it. All drivers in Texas must carry liability insurance on their vehicles or otherwise meet legal requirements for financial responsibility. Failure to do so could result in fines up to $1,000, suspension of your driver's license and motor vehicle registration, and impoundment of your vehicle for up to 180 days (at a cost of $15 per day).

Tarjeta de Seguro de Responsabilidad de Texas

Guarde esta tarjeta IMPORTANTE: Este tarjeta o una copia de su pliza de seguro debe ser mostrada cuando usted solicite o renueve su: registro de vehculo de motor licencia para conducir etiqueta de inspeccin de seguridad para su vehiculo Puede que usted tenga tambin que mostrar esta tarjeta o su pliza de seguro si tiene un accidente o si un oficial de la paz se la pide. Todos los conductores en Texas deben de tener seguro de responsabilidad para sus vehculos, o de otra manera llenar los requisitos legales de responsabilidad civil. Fallar en llenar este requisito pudiera resultar en multas de hasta $1,000, suspensin de su licencia para conducir y su registro de vehculo de motor, y la retencin de su vehiculo por un periodo de hasta 180 das (a un costo de $15 por da).

TEXAS LIABILITY INSURANCE CARD

THIS POLICY PROVIDES AT LEAST THE MINIMUM AMOUNTS OF LIABILITY INSURANCE REQUIRED BY THE TEXAS MOTOR VEHICLE SAFETY RESPONSIBILITY ACT FOR THE SPECIFIED VEHICLE AND NAMED INSUREDS AND MAY PROVIDE COVERAGE FOR OTHER PERSONS AND OTHER VEHICLES AS PROVIDED BY THE INSURANCE POLICY.
Insurance Company: To Report a Claim: For Claims Status: Agent/Producer:
OLD AMERICAN COUNTY MUTUAL FIRE INS CO (866)905-4461 (866)509-3509
1999 MAZDA 1996 CHEVROLET PROTEGE ES PICKUP 1500

(866) 563-9767
JM1BJ2214X0146225 2GCEC19W4T1209440

Vehicle Year Make Model VIN:

EL FARO MULTISERVICES 1616 N FRAZIER ST STE D CONROE, TX 77301 (936)539-5391

Policy Number: Effective Date: 06-29-2013 Named Insured:

BGT40026546

Expiration Date: 12-07-2013 Included Drivers: FERNANDO DELGADO DONNA MARIE BEATY

FERNANDO DELGADO 13631 TIMBER WEST LN CONROE, TX 77304

If any vehicle(s) or driver(s) listed above have changed, please contact your agent immediately.
ID_TX (2012/12)