A901E


State Farm Mutual Automobile Insurance Company05469-4-A MUTL VOL

PO Box 2358 DECLARATIONS PAGE
Bloomington IL 61702-2358
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NAMED INSURED
AT2 13-2902-4 A A POLICY NUMBER K68 0404-D21-13A __
001095 0058
CARTER, DEREK D POLICY PERIOD MAR 21 2024 to APR 21 2024
____ 4822 W 22ND PL 12:01 A.M. Standard Time
CICERO IL 60804-2401
STATE FARM PAYMENT PLAN NUMBER
____ 1080437756
____ AGENT __
____ __
ANDRADE INSURANCE AGENCY INC
____ 4355 W 26TH ST __
CHICAGO, IL 60623-5045

PHONE: (773)521-0216
DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED.
YOUR CAR
YEAR MAKE MODEL BODY STYLE VEHICLE ID. NUMBER CLASS
2014 HYUNDAI SANTA FE SPORT WG 5XYZT3LB1EG144977 300H601000
 
 
 


 
  


SYMBOLS COVERAGE
 
& LIMITS PREMIUMS
 
 
 


A Liability

Coverage



$67.14
Bodily Injury

Limits


Each Person,

Each Accident

$50,000
$100,000

Property 
Damage 
Limit 
Each Accident



$50,000



C Medical

Payments


Coverage 
$5.98
Limit - Each

Person


$10,000



D Comprehensive


Coverage

- $500 Deductible 
$20.50
G Collision


Coverage 
- $500 Deductible 
$65.48
R1 Car 
Rental 
and Travel
Expenses Coverage 
$4.65
Limit - Car
Rental 
Expense 
Each Day, 
Each Loss

$50 
$1,200

U Uninsured


Motor 
Vehicle Coverage 
$2.65
Bodily Injury

Limits


Each Person,

Each Accident

$50,000
$100,000

W Underinsured


Motor 
Vehicle Coverage 
$1.09
Bodily Injury

Limits


Each Person,

Each Accident

$50,000
$100,000

 
  


 Total premium for MAR 21 2024 to APR 21 2024. $167.49
 
 
 




CONTINUED

02497/00991 See Reverse Side
155-3866.2 04-2005 (o1a025hd)
I1SX0N (o1a025te)
B10
 A901E

State Farm Mutual Automobile Insurance Company05469-4-A MUTL VOL

PO Box 2358 DECLARATIONS PAGE
Bloomington IL 61702-2358
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NAMED INSURED 001095 0058 13-2902-4 A A POLICY NUMBER K68 0404-D21-13A
CARTER, DEREK D POLICY PERIOD MAR 21 2024 to APR 21 2024
4822 W 22ND PL 12:01 A.M. Standard Time
CICERO IL 60804-2401
STATE FARM PAYMENT PLAN NUMBER
____ 1080437756
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


IMPORTANT MESSAGES

For information or assistance with any insurance problem, be sure to contact your STATE FARM AGENT first. Your good
neighbor agent will be happy to help you. Section 143c of the Illinois Insurance Code requires notification of the following
addresses: State Farm Insurance Companies, PO Box 2345, Bloomington, Illinois 61702-2345.
Phone 1-800-424-1162 (within Illinois). Office Hours 8 A.M. to 4:30 P.M., Monday through Friday. Or Illinois Department of Insurance,
Consumer Services Section, Springfield, Illinois 62767. This message is provided by State Farm in compliance with Illinois law.

Replaced policy number K680404-13.

Your total renewal premium for OCT 21 2023 to APR 21 2024 is $1,002.94.

State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile
insurance is determined by many factors such as the coverages you have, where you live, the kind of car you drive, how your
car is used, who drives the car, and information from consumer reports.

You have the right to request, no more than once during a 12-month period, that your policy be re-rated using
a current credit-based insurance score. Re-rating could result in a lower rate, no change in rate, or a higher rate.

Notice of insurance information collection practices - personal , family, or household insurance transactions:
We often collect personal information from persons other than the individual or individuals listed on the policy.
Such personal information may, in certain circumstances, be disclosed to third parties without your authorization.
If you would like additional information concerning the collection and disclosure of personal information - and your right
to see and correct any personal information in your files - it will be furnished upon request.

EXCEPTIONS, POLICY BOOKLET & ENDORSEMENTS (See policy booklet & individual endorsements for coverage details.)

YOUR POLICY CONSISTS OF THIS DECLARATIONS PAGE, THE POLICY BOOKLET -
FORM 9813B, AND ANY ENDORSEMENTS THAT APPLY, INCLUDING THOSE ISSUED TO YOU
WITH ANY SUBSEQUENT RENEWAL NOTICE.
6128J AMENDATORY ENDORSEMENT.
6913B AMENDATORY ENDORSEMENT.

Agent: ANDRADE INSURANCE AGENCY INC

 Telephone: (773)521-0216
02498/00991
155-3866.2 04-2005 (o1a025hd) (o1a0254c)
Prepared MAR 25 2024 2902-BBA
I3SX0 (o1a025vd)
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 PLEASE ATTACH TO YOUR POLICY BOOKLET Policy Number: K68 0404-D21-13A
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