Interinsurance Exchange of the Automobile Club

PO Box 25001, Santa Ana, CA 92799-5001

AAA.com

Acknowledgement of Automobile Policy Effective Date

Named Insured: Ramirez, Bellen Policy Number: CAA 200804873

Policy Period: FROM: 11/24/2023 12:01 A.M. TO: 11/24/2024 12:01 A.M.

I understand that my Automobile Policy coverage does not go into effect prior to:

x 14 calendar days following the premium deposit.

x 12:01 A.M. STANDARD TIME on the “FROM” date for the policy period shown
above and on the Automobile Insurance Application.

By signing below, I acknowledge that no coverage will be provided by my automobile policy

for any losses that occur outside of the policy period.
Electronically Signed 2023-11-10 22:49:00 UTC - 47.216.244.238

Bellen Ramirez
Nintex AssureSign® 2af28428-b09c-4504-9b84-b0b601744a17 2023-11-10 14:51:15 (UTC-08:00)
Signature of Named Insured Date

9035 9/23
 Interinsurance Exchange of the Automobile Club
Automobile Insurance Coverages and Limits
NAMED INSURED MEMBERSHIP NUMBER POLICY NUMBER
Ramirez, Bellen 98209603 CAA200804873

A. APPLICATION INFORMATION:
APPLICANT’S NAME AND MAILING ADDRESS: APPLICANT’S RESIDENCE ADDRESS, IF DIFFERENT:
Ramirez, Bellen
460 ALAMEDA ST
Blythe CA 92225
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
Ramirez, Bellen No 11-03-1981 2005 Policy Holder Yes
Ramirez, Julian Yes 02-27-2006 Other 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
2021 BMW X5 4D4D,
HOND/ACCORD 4WD.XDRIVE
SPORT SPE 15,000
14828 234,000
10 AAAVerified
OnBoard Yes
No $1,000
500 $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)
264
30,000
Property Damage 10,000 (each occurrence) 210
Medical Payments (each person)

Excess Medical Payments (each person)

Uninsured and Underinsured Motorist Bodily Injury 15,000 (each person) 150
30,000 (each accident)
Uninsured Collision

Uninsured Deductible Waiver Yes Included

Comprehensive (Comp.) (See Deductibles Above) 322
Collision (See Deductibles Above) 922
Car Rental Expense (See Above)

ANNUAL VEHICLE PREMIUM: 1,868

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: 1,868

Electronically Signed 2023-11-10 22:48:48 UTC - 47.216.244.238

Bellen Ramirez 2023-11-10 14:51:15 (UTC-08:00)

X Nintex AssureSign®

Applicant’s Signature
91919d57-a07b-443b-9e2c-b0b601744a21

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.

11/24/2023
Effective ________________________________12:01 A.M. Pacific Standard Time
CAA200804873
Forming a part of Policy No. ___________________________
issued by the INTERINSURANCE EXCHANGE OF THE AUTOMOBILE CLUB.
Ramirez, Bellen
Named Insured: _____________________________________
Designated Person(s):
______________________________________________
Ramirez, Julian ______________________________________________

______________________________________________ ______________________________________________

______________________________________________ ______________________________________________

______________________________________________ ______________________________________________

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 2023-11-10 22:48:22 UTC - 47.216.244.238

Bellen Ramirez
Nintex AssureSign® 915b8cc2-1380-436d-92f2-b0b601744a32 2023-11-10 14:51:15 (UTC-08:00)
Accepted ____________________________________________________________________________________________
Signature of Insured Date Hour
Bellen Ramirez
Print Name Here
ACSC Management Services, Inc.
ATTORNEY-IN-FACT
2184
Ed. 4-17
 Interinsurance Exchange of the Automobile Club
Automobile Insurance Application
NAMED INSURED MEMBERSHIP NUMBER POLICY NUMBER
Ramirez, Bellen 004-98209603 CAA200804873
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
Other
Ramirez Adrian M 04-16-2009

3. POLICY PERIOD: (Pacific Standard Time) 12-MONTH POLICY PREMIUM TOTAL: $ 1,868
FROM: Month November Day 24 Year 2023 12:01 A.M. TO: Month November Day 24 Year 2024 12:01 A.M.

WARNING: READ THIS NOTICE CAREFULLY!

By signing this application, you acknowledge that no coverage will be provided by this policy prior to the “FROM” date for
the Policy Period shown above. Coverage will not be provided for any losses that occur outside of the Policy Period.
Please read the following information in its entirety.

IMPORTANT INFORMATION AND BINDER OF INSURANCE:

While we review your application for insurance, coverage is bound effective at 12:01 A.M. STANDARD TIME at the address of the named insured as stated
herein on the “FROM” date for the policy period shown above. 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. When the application is approved, the policy issued to you will replace the binder. We may cancel this binder by mailing written
notice of cancellation to the named insured at the address shown on the application in accordance with the policy provisions. 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.
It is your responsibility to choose the level of insurance protection that best suits your needs by selecting and maintaining coverages and limits that will adequately
protect you and your property in the event of a loss.
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.
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 to 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.
For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to
obtain or amend insurance
Electronically Signed
coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state
2023-11-10 22:47:58 UTC - 47.216.244.238
prison.
Bellen Ramirez
Nintex AssureSign® 1ed5023d-5b7e-4d3f-8c40-b0b601744a43 2023-11-10 14:51:15 (UTC-08:00)

X a.m. p.m.
Applicant’s Signature Date Time

X Co-Applicant’s Signature Date Time

a.m. p.m.

30551 9/23 Insurance provided to qualified Auto Club members by the Interinsurance Exchange of the Automobile Club. Pg.  of 
 Interinsurance Exchange of the Automobile Club


Ramirez, Bellen
Policy Number: CAA200804873

460 ALAMEDA ST
Blythe CA 92225


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 2023-11-10 22:47:49 UTC - 47.216.244.238

Bellen Ramirez
Nintex AssureSign® a59aa02d-d7ef-4c6b-96fd-b0b601744a4e
2023-11-10 14:51:15 (UTC-08:00)

8216
Ed. 01-07
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Electronically Signed 2023-11-10 22:47:15 UTC - 47.216.244.238
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Bellen Ramirez
2023-11-10 14:51:15 (UTC-08:00)
Bellen Ramirez Nintex AssureSign® 1d7c0eea-6f23-4edb-8fc1-b0b601744a60

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659683 16 004-98209603 Bellen Ramirez
'''&)3456788&9& !"#$%%&!'$(&)* :;<=>?@"8>&9 (83A8;B?C4&9 (83A8;&!<38 ** Sensitive Regulated Data ** !"#$%&'"&(