Preview
Filing # 134463040 E-Filed 09/13/2021 01:41:04 PM
IN THE CIRCUIT COURT OF THE 15TH
JUDICIAL CIRCUIT IN AND FOR PALM
BEACH COUNTY, FLORIDA.
CASE NO: 50-2021-CA-007517-XXXX-MB
JAMES N. MANOLAKOS,
Plaintiff,
vs.
RONALD PAUL HIMEBACK,
Defendant.
/
AMENDED COMPLAINT
Plaintiff, JAMES N, MANOLAKOS (hereinafter MR. MANOLAKOS),
sues Defendants RONALD PAUL HIMEBACK (hereinafter MR. HIMEBACK)
and SAFECO INSURANCE COMPANY OF ILLINOIS (hereinafter SAFECO)
and alleges:
1. This is an action for damages that exceed the sum of $30,000 and for
declaratory relief.
2. At all times material hereto, MR. MANOLAKOS is and was a resident and
domiciliary of Palm Beach County, Florida.
3. At all times material hereto, MR. HIMEBACK was and is a resident and
domiciliary of Palm Beach County, Florida.
4. At all times material hereto, SAFECO was an insurer authorized by the Florida
Department of Financial Services to do business in Florida with agents for the
1
CHEN. DAIAARCACUAAIINTY Cl INGEDU ARDIIV7ZN FLED NaMaINNNA NA A4-NA DNA
Pn. PAL DLA VUUINE TT, PL, VUOL I mDNUeey, ULLIAN, vorlureue! Ut ut oive>
transaction of its customary business in Palm Beach County, Florida.
. On or about 11-08-2020 at 3:55 PM, MR. HIMEBACK operated a motor
vehicle on Handcock Creek Road in the Riverwalk community in West Palm
Beach, Palm Beach County, Florida,
COUNT I
AUTO NEGLIGENCE
- MR. MANOLAKOS re-alleges and incorporates by reference allegations 1-5 as
cat Fanth alarm
put LOrul aUOVE,
. At the above date, time and place, MR. HIMEBACK negligently operated or
maintained the motor vehicle he was driving so that it struck MR.
MANOLAKOS as a pedestrian,
- More specifically, MR. HIMEBACK negligently operated the motor vehicle he
was occupying by at least, but not limited to, the following acts and/or
omissions:
A. Driving too fast for conditions;
B. Failing to maintain a proper lookout;
C. Failing to exercise due care.
AS a direct resuit of the above, ihe vehicle MR. HIMEBACK was operating
violently struck MR. MANOLAKOS as he was walking as a pedestrian and
MR. MANOLAKOS suffered bodily injury and resulting disability,
disfigurement, expense of medical and nursing care and treatment, loss of
2earnings, loss of ability to earn money, loss of capacity for the enjoyment of
life, loss of ordinary and necessary household services and aggravation of an
existing disease or physical defect or activation of a latent disease or physical
defect. These losses are permanent or continuing in nature and MR,
MANOLAKOS will suffer these losses in the future. MR. MANOLAKOS also
claims damages for pain, suffering, mental anguish, and inconvenience based
on having satisfied the tort threshold of the Florida Motor Vehicle No-Fault
Law.
WHEREFORE, MR, MANOLAKOS demands compensatory damages
against MR, HIMEBACK together with his costs pursuant to F.S. §§92.231,
57.041, 57.071 and Fla. R, Civ. Pro. 1.390(b) and further demands trial by jury.
COUNT II
REQUEST FOR DECLARATORY RELIEF UNDER E.S. §86.11 ET SEQ ON
UM COVERAGE ISSUES WITH REGARD TO SAFECO AUTO POLICY
MR. MANOLAKOS re-alleges and incorporates by reference allegations 1-5
and 7 and 9 above,
11. MR. HIMEBACK had a policy of auto insurance which did not provide
Suificient bodily injury Liability insurance iimits to compensate MR.
MANOLAKOS for all the personal injuries MR. MANOLAKOS sustained in
the above described 11-08-2020 motor vehicle verses pedestrian accident.
12. MR. MANOLAKOS suffered bodily injury because of the negligence of an
3uninsured motorist MR. HIMEBACK in the1 1-08-2020 motor vehicle verses
pedestrian accident as set forth above in Count I of this Complaint.
13. SAFECO issued a policy ##X6010248 which provides uninsured motorist
(hereinafter UM) coverage.
14. The policy declarations for above-described SAFECO policy #X6010248 is
attached as Exhibit A. MR. MANOLAKOS has not been furnished with a full
and complete copy of the policy to attach but SAFECO has the full policy.
15. The above-described SAFECO policy #X6010248 covered MR.
MANOLAKOS as a named insured with UM coverage for the 11-08-2020
motor vehicle verses pedestrian accident.
16, The UM coverage of the above-described SAFECO policy #X6010248 is
governed by Florida law and more specifically by F.S. §627.727.
17. SAFECO “steps into the shoes” of MR. HIMEBACK by the terms of the
above- described SAFECO nolicy #6010248 and pursuant to 8, §627.727
and the Florida case law thereunder.
18. MR. MANOLAKOS gave timely written notice to SAFECO that he was
presenting bodily injury claims for injuries sustained in the 11-08-2020 motor
vehicle versus pedestrian accident under the UM coverage of the above-
described SAFECO policy #X6010248.
19. MR. MANOLAKOS complied with all his other duties related the UMcoverage under the above-described SAFECO policy #X6010248.
20. MR. MANOLAKOS fulfilled all conditions precedent under the above-
described SAFECO policy # X6010248 to have SAFECO consider MR.
MANOLAKOS’s bodily inury claims under that nolicv’s UM coverage and to
bring this action.
21.SAFECO acknowledged UM coverage exits under the above SAFECO policy
#X6010248 for MR. MANOLAKOS’s injuries sustained in the 11-08-2020
motor vehicle verses pedestrian accident.
22, The UM coverage under the above described SAFECO policy ##X6010248
covers all compensatory damages which the uninsured motorist MR.
HIMEBACK legally owes MR. MANOLAKOS under Count I, which include
bodily injury and resulting disability, disfigurement, expense of medical and
nursing care and treatment, loss of earnings, loss of ability to earn money, loss
of canacity for the eniovment of life, loss of ordinary and necessary household
services and aggravation of an existing disease or physical defect or activation
of a latent disease or physical defect. These losses are either permanent or
continuing in nature and MR. MANOLAKOS also claims as losses covered
under UM his losses in the future. MR. MANOLAKOS also claims damages
for pain, suffering, mental anguish, and inconvenience to be covered under theUM of the above-described SAFECO policy #X6010248 based on having
satisfied the tort threshold of the Florida Motor Vehicle No-Fault Law.
23, SAFECO has conditionally tendered its policy limits to MR. MANOLAKOS
for the bodily injuries MR. MANOLAKOS sustained as a result of the 11-08-
2020 motor vehicle verses pedestrian accident.
24, SAFECO tendered the UM policy limits on the condition that MR.
MANOLAKOS accept a release written by SAFECO.
25. MR. MANOLAKOS does not want to accept SAFECO’s release,
26, SAFECO has failed to unconditionally tender any part of the UM benefits for
the bodily injuries MR. MANOLAKOS claims to have sustained.
27, There is a dispute between SAFECO and MR. MANOLAKOS over whether
MR. MANOLAKOS is required to sign any release and/or whether the release
proposed by SAFECO is appropriate.
28, MR. MANOLAKOS would like to propose his own release.
29. Due to the above dispute over whether any release and/or whether the release
proposed by SAFECO is appropriate, MR. MANOLAKOS may properly join
SAFECO in this lawsuit together with MR, HIMEBACK as co-defendants.
30. Based upon the above dispute, MR. MANOLAKOS is in doubt as to his rights
under the policy issued by SAFECO and MR. MANOLAKOS is in need of
immediate judicial determination of his rights with regard to the signing anyrelease and/or the release proposed by SAFECO. WHEREFORE, MR.
MANOLAKOS requests:
A. That the court order full disclosure of all documents and allow full and
liberal discovery of all facts that may lead to admissible evidence relevant to
the determinations herein including nraductian of the camnlete noaliev of
sete CO CEC erwin GICAtp PrOWUCTOLL UL LE CObEpaTer
insurance and a complete copy of the written material in the possession of
SAFECO that would shed light on the issues involved herein;
. That the court issue a declaratory judgment determining the issues set forth
above including whether Plaintiff must sign any release and whether the
release proposed by SAFECO is appropriate and whether the court may
require a different release written by MR, MANOLAKOS to be used.
. That the court determine the applicable law, including the provisions of
Florida Statutes, that apply to the policy and to the parties and that the court
declare that each policy provision not in conformity with Florida law be
amended to conform with Florida law;
D. That the court determine and declare any other material matters pertaining to
the coverage or otherwise as to the respective rights and responsibilities of
the party under the policy as needed to do complete justice in this case;
E. That upon Plaintiff prevailing on any of the above issues related to the UM
coverage, that the court consider and determine which hours of work
nerformed hv the undarcionad ware related to TIM coverage and award anv
Porscrinee oy MLGUoIgueG Tere luau to Ula CO rerape
such attorneys’ fees owed by SAFECO as a result of engendering these
issues.
WHEREFORE, MR. MANOLAKOS demands declaratory relief pursuant to
F.S. §86.011 et seq, with regard to the SAFECO policy issued under policy #
6010248 and MR. MANOLAKOS further demands attorneys’ fees pursuant to
FS. §627.428 and F.S. §627.727(8), legal assistant fees pursuant to F.S. §57.104
and costs pursuant to F.S. §92.231, Rule 1.390(c), F.S. §57.041 and F.S. §57.71against SAFECO,
THEREBY CERTIFY that a true and correct copy of the foregoing has been
served by filing it with the clerk of the court on this [ Bt of September 2021 and
by email true and accurate conies hereof to: detanhana@nclacal cam
y and accurate conies hereof to: d:
OU Panwa AZO ULW BadeCULiy
LOlds@oslegal.com, volds@oslegal.com, PPecaro@lawdrive.com,
gigi@lawdrive.com, pastillman@gmail.com, phil@baderstillman.com,
alexis@baderstillman.com,
Diego C. Asencio, P.A.
4440 PGA Blvd. Suite 600
Palm Beach Gardens, FL 33410
Tel: (561) 844-0840
Email /diego6, daol.co
Ve 4 // 7
Byt
Diggé C. Asencio, Esq.
Florida Bar #: 352942EXHIBIT A~ ~\
“REPRINTED | THEARCHIVE. THE ORIGINAL TRANSACTIONMAY INCLUDEADC —-ALFORMS **
POLICY NUMBER: X6010248
Sei Insurance.
A Liberty Mutual Company
SAFECO INSURANCE COMPANY OF ILLINOIS
AUTOMOBILE POLICY DECLARATIONS
NAMED INSURED;
POLICY CHANGE
ZAM ES MANO L BKOS CHANGED EFFECTIVE: MAY 5 2020
3756 HANCOCK ci POLICY PERIOD FROM: MAY 5 2020
2790 HANCOCK’ CREEK RO :
WEST PALM BEACH FL 33411-5732 TO: MAY 5 2021
at 12:01 A.M, standard time at
the address of the insured as
AGENT: stated herein,
HORACE MANN SERVICE CORP AGENT TELEPHONE:
UNITED BUSINESS MGT -800-578-
9270 INDIANTOWN RD aapop=o7ese7pe
JUPITER FL 33478-2206
RATED DRIVERS JAMES MANOLAKOS, GAIL MANOLAKOS
2016 JEEP GRAND CHEROKEE LAR 4 DOOR ID# 1C4RIFAGIGC445123
LOSS PAYEE CAPITAL ONE AUTO FINANCE
2011 TOYOTA AVALON BASE/LIMITE 4 DOOR SEDAN
ID# 4TLBK3DBXBU434398
LOSS PAYEE GOLD COAST FCU
Insurance is afforded only for the coverages for which limits of liability or
Premium charges are indicated.
[COVERAGES 2016 JEEP LIMITS | PREMIUMS | 2011 TOYT LIMITS | PREMIUMS]
LIABILITY:
BODILY INJURY $250,000 § 957.10 $250,000 § 858.30
Each Person Each Person
00, 000 $500,000
Each Occurrence Each Occurrence
PROPERTY DAMAGE 000 244.80 $100,000 206.50
Each Occurrence Each Occurrence
PIP 129.60 158.80
WORK LOSS EXCL.
=NAMED_INSURED
& RELATIVES
$1.000
DEDUCTIBLE
APPLIES TO
NAMED INSURED
& RELATIVES
UNINSURED MOTORISTS (NON-STACKED LIMITS):
BODILY INJURY 60,000 294.00 $100,000 260.30
Each Person Each Person
$300,000 $300,000
Each Accident Each Accident
COMPREHENSIVE Actual Cash Value 86.70 Actual Cash Value 79.30
L€ss 3500 Deauctibie Less $500 Deductible
COLLISION Actual Cash Value 353.70 Actual Cash Value 286.00
Less $500 Deductible
Less $500 Deductible
re ae COVERAGES:
LOSS OF USE $50 Per Day/$1500 Max
TOTAL $
$50 Per Day/$1500 Max 18.60
TOTAL $ 1,867.80
~CONTINUED-
P © BOX 515097, LOS ANGELES, CA 90051
SA-IESTIEP 9/90 Page 1 of 2 DATE PREPARED: APR. 15 2020™ ™
‘WY REPRINTED —'THEARCHIVE, THEORIGINAL TRANSAGTIONMAY INCLUDEADL —-ALFORMS ***
NUIMRFR: yan10248
SAFECO INSURANCE COMPANY OF ILLINOIS
AUTOMOBILE POLICY DECLARATIONS
(CONTINUED)
TOTAL EACH VEHICLE:
4,
PREMIUM SUMMARY PREMIUM
VEHICLE COVERAGES $ 3,963.20
DISCOUNTS & SAFECO SAFETY REWARDS You saved $1,270.70 Included
TOTAL 12 MONTH PREMIUM FOR ALL VEHICLES ....scssceecseesereeereeesesseee $ 37963420
You Angee $1,270.70 aies BY QUALIFYING FOR THE FOLLOWING DISCOUNTS:
ntj-Loc!
Anti-Theft
Advance Quoting
Low Mileage
sister Free
Coverage
Homeowners
Multi-Cap
Both Side Air Bag
Preferred Payment Method
SA-1698/EP 9/20 Page 2 of 2
na
Preview
Filing # 134463040 E-Filed 09/13/2021 01:41:04 PM IN THE CIRCUIT COURT OF THE 15TH JUDICIAL CIRCUIT IN AND FOR PALM BEACH COUNTY, FLORIDA. CASE NO: 50-2021-CA-007517-XXXX-MB JAMES N. MANOLAKOS, Plaintiff, vs. RONALD PAUL HIMEBACK, Defendant. / AMENDED COMPLAINT Plaintiff, JAMES N, MANOLAKOS (hereinafter MR. MANOLAKOS), sues Defendants RONALD PAUL HIMEBACK (hereinafter MR. HIMEBACK) and SAFECO INSURANCE COMPANY OF ILLINOIS (hereinafter SAFECO) and alleges: 1. This is an action for damages that exceed the sum of $30,000 and for declaratory relief. 2. At all times material hereto, MR. MANOLAKOS is and was a resident and domiciliary of Palm Beach County, Florida. 3. At all times material hereto, MR. HIMEBACK was and is a resident and domiciliary of Palm Beach County, Florida. 4. At all times material hereto, SAFECO was an insurer authorized by the Florida Department of Financial Services to do business in Florida with agents for the 1 CHEN. DAIAARCACUAAIINTY Cl INGEDU ARDIIV7ZN FLED NaMaINNNA NA A4-NA DNA Pn. PAL DLA VUUINE TT, PL, VUOL I mDNUeey, ULLIAN, vorlureue! Ut ut oive> transaction of its customary business in Palm Beach County, Florida. . On or about 11-08-2020 at 3:55 PM, MR. HIMEBACK operated a motor vehicle on Handcock Creek Road in the Riverwalk community in West Palm Beach, Palm Beach County, Florida, COUNT I AUTO NEGLIGENCE - MR. MANOLAKOS re-alleges and incorporates by reference allegations 1-5 as cat Fanth alarm put LOrul aUOVE, . At the above date, time and place, MR. HIMEBACK negligently operated or maintained the motor vehicle he was driving so that it struck MR. MANOLAKOS as a pedestrian, - More specifically, MR. HIMEBACK negligently operated the motor vehicle he was occupying by at least, but not limited to, the following acts and/or omissions: A. Driving too fast for conditions; B. Failing to maintain a proper lookout; C. Failing to exercise due care. AS a direct resuit of the above, ihe vehicle MR. HIMEBACK was operating violently struck MR. MANOLAKOS as he was walking as a pedestrian and MR. MANOLAKOS suffered bodily injury and resulting disability, disfigurement, expense of medical and nursing care and treatment, loss of 2earnings, loss of ability to earn money, loss of capacity for the enjoyment of life, loss of ordinary and necessary household services and aggravation of an existing disease or physical defect or activation of a latent disease or physical defect. These losses are permanent or continuing in nature and MR, MANOLAKOS will suffer these losses in the future. MR. MANOLAKOS also claims damages for pain, suffering, mental anguish, and inconvenience based on having satisfied the tort threshold of the Florida Motor Vehicle No-Fault Law. WHEREFORE, MR, MANOLAKOS demands compensatory damages against MR, HIMEBACK together with his costs pursuant to F.S. §§92.231, 57.041, 57.071 and Fla. R, Civ. Pro. 1.390(b) and further demands trial by jury. COUNT II REQUEST FOR DECLARATORY RELIEF UNDER E.S. §86.11 ET SEQ ON UM COVERAGE ISSUES WITH REGARD TO SAFECO AUTO POLICY MR. MANOLAKOS re-alleges and incorporates by reference allegations 1-5 and 7 and 9 above, 11. MR. HIMEBACK had a policy of auto insurance which did not provide Suificient bodily injury Liability insurance iimits to compensate MR. MANOLAKOS for all the personal injuries MR. MANOLAKOS sustained in the above described 11-08-2020 motor vehicle verses pedestrian accident. 12. MR. MANOLAKOS suffered bodily injury because of the negligence of an 3uninsured motorist MR. HIMEBACK in the1 1-08-2020 motor vehicle verses pedestrian accident as set forth above in Count I of this Complaint. 13. SAFECO issued a policy ##X6010248 which provides uninsured motorist (hereinafter UM) coverage. 14. The policy declarations for above-described SAFECO policy #X6010248 is attached as Exhibit A. MR. MANOLAKOS has not been furnished with a full and complete copy of the policy to attach but SAFECO has the full policy. 15. The above-described SAFECO policy #X6010248 covered MR. MANOLAKOS as a named insured with UM coverage for the 11-08-2020 motor vehicle verses pedestrian accident. 16, The UM coverage of the above-described SAFECO policy #X6010248 is governed by Florida law and more specifically by F.S. §627.727. 17. SAFECO “steps into the shoes” of MR. HIMEBACK by the terms of the above- described SAFECO nolicy #6010248 and pursuant to 8, §627.727 and the Florida case law thereunder. 18. MR. MANOLAKOS gave timely written notice to SAFECO that he was presenting bodily injury claims for injuries sustained in the 11-08-2020 motor vehicle versus pedestrian accident under the UM coverage of the above- described SAFECO policy #X6010248. 19. MR. MANOLAKOS complied with all his other duties related the UMcoverage under the above-described SAFECO policy #X6010248. 20. MR. MANOLAKOS fulfilled all conditions precedent under the above- described SAFECO policy # X6010248 to have SAFECO consider MR. MANOLAKOS’s bodily inury claims under that nolicv’s UM coverage and to bring this action. 21.SAFECO acknowledged UM coverage exits under the above SAFECO policy #X6010248 for MR. MANOLAKOS’s injuries sustained in the 11-08-2020 motor vehicle verses pedestrian accident. 22, The UM coverage under the above described SAFECO policy ##X6010248 covers all compensatory damages which the uninsured motorist MR. HIMEBACK legally owes MR. MANOLAKOS under Count I, which include bodily injury and resulting disability, disfigurement, expense of medical and nursing care and treatment, loss of earnings, loss of ability to earn money, loss of canacity for the eniovment of life, loss of ordinary and necessary household services and aggravation of an existing disease or physical defect or activation of a latent disease or physical defect. These losses are either permanent or continuing in nature and MR. MANOLAKOS also claims as losses covered under UM his losses in the future. MR. MANOLAKOS also claims damages for pain, suffering, mental anguish, and inconvenience to be covered under theUM of the above-described SAFECO policy #X6010248 based on having satisfied the tort threshold of the Florida Motor Vehicle No-Fault Law. 23, SAFECO has conditionally tendered its policy limits to MR. MANOLAKOS for the bodily injuries MR. MANOLAKOS sustained as a result of the 11-08- 2020 motor vehicle verses pedestrian accident. 24, SAFECO tendered the UM policy limits on the condition that MR. MANOLAKOS accept a release written by SAFECO. 25. MR. MANOLAKOS does not want to accept SAFECO’s release, 26, SAFECO has failed to unconditionally tender any part of the UM benefits for the bodily injuries MR. MANOLAKOS claims to have sustained. 27, There is a dispute between SAFECO and MR. MANOLAKOS over whether MR. MANOLAKOS is required to sign any release and/or whether the release proposed by SAFECO is appropriate. 28, MR. MANOLAKOS would like to propose his own release. 29. Due to the above dispute over whether any release and/or whether the release proposed by SAFECO is appropriate, MR. MANOLAKOS may properly join SAFECO in this lawsuit together with MR, HIMEBACK as co-defendants. 30. Based upon the above dispute, MR. MANOLAKOS is in doubt as to his rights under the policy issued by SAFECO and MR. MANOLAKOS is in need of immediate judicial determination of his rights with regard to the signing anyrelease and/or the release proposed by SAFECO. WHEREFORE, MR. MANOLAKOS requests: A. That the court order full disclosure of all documents and allow full and liberal discovery of all facts that may lead to admissible evidence relevant to the determinations herein including nraductian of the camnlete noaliev of sete CO CEC erwin GICAtp PrOWUCTOLL UL LE CObEpaTer insurance and a complete copy of the written material in the possession of SAFECO that would shed light on the issues involved herein; . That the court issue a declaratory judgment determining the issues set forth above including whether Plaintiff must sign any release and whether the release proposed by SAFECO is appropriate and whether the court may require a different release written by MR, MANOLAKOS to be used. . That the court determine the applicable law, including the provisions of Florida Statutes, that apply to the policy and to the parties and that the court declare that each policy provision not in conformity with Florida law be amended to conform with Florida law; D. That the court determine and declare any other material matters pertaining to the coverage or otherwise as to the respective rights and responsibilities of the party under the policy as needed to do complete justice in this case; E. That upon Plaintiff prevailing on any of the above issues related to the UM coverage, that the court consider and determine which hours of work nerformed hv the undarcionad ware related to TIM coverage and award anv Porscrinee oy MLGUoIgueG Tere luau to Ula CO rerape such attorneys’ fees owed by SAFECO as a result of engendering these issues. WHEREFORE, MR. MANOLAKOS demands declaratory relief pursuant to F.S. §86.011 et seq, with regard to the SAFECO policy issued under policy # 6010248 and MR. MANOLAKOS further demands attorneys’ fees pursuant to FS. §627.428 and F.S. §627.727(8), legal assistant fees pursuant to F.S. §57.104 and costs pursuant to F.S. §92.231, Rule 1.390(c), F.S. §57.041 and F.S. §57.71against SAFECO, THEREBY CERTIFY that a true and correct copy of the foregoing has been served by filing it with the clerk of the court on this [ Bt of September 2021 and by email true and accurate conies hereof to: detanhana@nclacal cam y and accurate conies hereof to: d: OU Panwa AZO ULW BadeCULiy LOlds@oslegal.com, volds@oslegal.com, PPecaro@lawdrive.com, gigi@lawdrive.com, pastillman@gmail.com, phil@baderstillman.com, alexis@baderstillman.com, Diego C. Asencio, P.A. 4440 PGA Blvd. Suite 600 Palm Beach Gardens, FL 33410 Tel: (561) 844-0840 Email /diego6, daol.co Ve 4 // 7 Byt Diggé C. Asencio, Esq. Florida Bar #: 352942EXHIBIT A~ ~\ “REPRINTED | THEARCHIVE. THE ORIGINAL TRANSACTIONMAY INCLUDEADC —-ALFORMS ** POLICY NUMBER: X6010248 Sei Insurance. A Liberty Mutual Company SAFECO INSURANCE COMPANY OF ILLINOIS AUTOMOBILE POLICY DECLARATIONS NAMED INSURED; POLICY CHANGE ZAM ES MANO L BKOS CHANGED EFFECTIVE: MAY 5 2020 3756 HANCOCK ci POLICY PERIOD FROM: MAY 5 2020 2790 HANCOCK’ CREEK RO : WEST PALM BEACH FL 33411-5732 TO: MAY 5 2021 at 12:01 A.M, standard time at the address of the insured as AGENT: stated herein, HORACE MANN SERVICE CORP AGENT TELEPHONE: UNITED BUSINESS MGT -800-578- 9270 INDIANTOWN RD aapop=o7ese7pe JUPITER FL 33478-2206 RATED DRIVERS JAMES MANOLAKOS, GAIL MANOLAKOS 2016 JEEP GRAND CHEROKEE LAR 4 DOOR ID# 1C4RIFAGIGC445123 LOSS PAYEE CAPITAL ONE AUTO FINANCE 2011 TOYOTA AVALON BASE/LIMITE 4 DOOR SEDAN ID# 4TLBK3DBXBU434398 LOSS PAYEE GOLD COAST FCU Insurance is afforded only for the coverages for which limits of liability or Premium charges are indicated. [COVERAGES 2016 JEEP LIMITS | PREMIUMS | 2011 TOYT LIMITS | PREMIUMS] LIABILITY: BODILY INJURY $250,000 § 957.10 $250,000 § 858.30 Each Person Each Person 00, 000 $500,000 Each Occurrence Each Occurrence PROPERTY DAMAGE 000 244.80 $100,000 206.50 Each Occurrence Each Occurrence PIP 129.60 158.80 WORK LOSS EXCL. =NAMED_INSURED & RELATIVES $1.000 DEDUCTIBLE APPLIES TO NAMED INSURED & RELATIVES UNINSURED MOTORISTS (NON-STACKED LIMITS): BODILY INJURY 60,000 294.00 $100,000 260.30 Each Person Each Person $300,000 $300,000 Each Accident Each Accident COMPREHENSIVE Actual Cash Value 86.70 Actual Cash Value 79.30 L€ss 3500 Deauctibie Less $500 Deductible COLLISION Actual Cash Value 353.70 Actual Cash Value 286.00 Less $500 Deductible Less $500 Deductible re ae COVERAGES: LOSS OF USE $50 Per Day/$1500 Max TOTAL $ $50 Per Day/$1500 Max 18.60 TOTAL $ 1,867.80 ~CONTINUED- P © BOX 515097, LOS ANGELES, CA 90051 SA-IESTIEP 9/90 Page 1 of 2 DATE PREPARED: APR. 15 2020™ ™ ‘WY REPRINTED —'THEARCHIVE, THEORIGINAL TRANSAGTIONMAY INCLUDEADL —-ALFORMS *** NUIMRFR: yan10248 SAFECO INSURANCE COMPANY OF ILLINOIS AUTOMOBILE POLICY DECLARATIONS (CONTINUED) TOTAL EACH VEHICLE: 4, PREMIUM SUMMARY PREMIUM VEHICLE COVERAGES $ 3,963.20 DISCOUNTS & SAFECO SAFETY REWARDS You saved $1,270.70 Included TOTAL 12 MONTH PREMIUM FOR ALL VEHICLES ....scssceecseesereeereeesesseee $ 37963420 You Angee $1,270.70 aies BY QUALIFYING FOR THE FOLLOWING DISCOUNTS: ntj-Loc! Anti-Theft Advance Quoting Low Mileage sister Free Coverage Homeowners Multi-Cap Both Side Air Bag Preferred Payment Method SA-1698/EP 9/20 Page 2 of 2 na