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Filing # 194435789 E-Filed 03/20/2024 01:42:01 PM
IN THE CIRCUIT COURT FOR THE SEVENTH JUDICIAL CIRCUIT,
IN AND FOR FLAGLER COUNTY, FLORIDA
CASE NO.: 2024 CA 000071
DIVISION: 49
JANICE SWANK,
Plaintiff,
vs.
KAREN MILDRED POWELL and
AUTO CLUB INSURANCE COMPANY
OF FLORIDA, a Florida Profit Corporation
Defendant.
/
AMENDED COMPLAINT
COMES NOW Plaintiff, JANICE SWANK, by and through the undersigned counsel,
and hereby sues Defendants, KAREN MILDRED POWELL and AUTO CLUB
INSURANCE COMPANY OF FLORIDA, a Florida Profit Corporation, and alleges as
follows:
1 This is an action for damages in excess of Fifty Thousand and One Dollars
($50,001.00), exclusive of interest, attorneys’ fees, and costs (the estimated value of Plaintiffs
claim is in excess of the minimum jurisdictional threshold required by this Court).
Accordingly, Plaintiff entered “$50,001.00” on the Civil Cover Sheet for the “estimated
amount of the claim,” as required in the preamble to the Civil Cover Sheet, for jurisdictional
purposes only (the Florida Supreme Court has ordered that the estimated “amount of claim”
be set forth in the Civil Cover Sheet for data collection and clerical purposes only). The actual
value of the Plaintiff's claim will be determined by a fair and just jury in accordance with
Article 1, Section 21, Fla. Const.
2 At all times material hereto, Plaintiff, JANICE SWANK, was a resident of
Palm Coast, Flagler County, Florida.
Electronically Received in the Office of the Clerk of the Circuit Court - Flagler County, Florida - 03/20/2024 02:57 PM - DIN: 16
3 At all times material hereto, Defendant, KAREN MILDRED POWELL, was
a resident of Daytona Beach, Volusia County, Florida.
4 At all times material hereto, Defendant AUTO CLUB INSURANCE
COMPANY OF FLORIDA was a Florida Profit Corporation licensed and doing business in
the State of Florida.
5 The motor vehicle collision, which is the basis of this action, occurred in Palm
Coast, Flagler County, Florida.
COUNT I - PLAINTIFF’S LIABILITY CLAIM AGAINST DEFENDANT,
KAREN MILDRED POWELL
6 Plaintiff realleges and incorporates by reference paragraphs one (1) through
five (5), and further states:
7 On or about April 2, 2023, Plaintiff, JANICE SWANK, was a passenger in a
2020 Volkswagen motor vehicle that was owned and operated by Donna Raposa and was
stopped for a red traffic light at Town Center Boulevard in Palm Coast, Flagler County,
Florida.
8 On or about April 2, 2023, Defendant, KAREN MILDRED POWELL, was
the owner and operator of a 2016 Jeep motor vehicle.
9. At the above-stated time and place, Defendant, KAREN MILDRED
POWELL, negligently owned, operated, and/or maintained her vehicle in such a way as to
cause a collision with the motor vehicle that Plaintiff, JANICE SWANK was a passenger in.
10. As a result of the negligence of Defendant, KAREN MILDRED POWELL, as
set forth hereinabove, Plaintiff JANICE SWANK, suffered bodily injury and resulting pain
and suffering, disability, disfigurement, mental anguish, loss of capacity for the enjoyment of
life, expense of hospitalization, medical and nursing care and treatment, loss of earnings, loss
of ability to earn money, and/or aggravation of a previously existing condition. The losses
are either permanent or continuing and the Plaintiff will suffer the losses in the future.
WHEREFORE, Plaintiff, JANICE SWANK, demands judgment against the
Defendant, KAREN MILDRED POWELL, for damages in excess of Fifty Thousand One
Dollars ($50,001.00), exclusive of interest, attorney’s fees, and costs, and the Plaintiff
demands a trial by jury.
COUNT I - PLAINTIFF’S CLAIM OF NEGLIGENCE AS TO DEFENDANT,
AUTO CLUB INSURANCE COMPANY OF FLORIDA
Plaintiff realleges and incorporates by reference paragraphs one (1) through ten (10),
and further states:
11. As a result of the negligence of underinsured Defendant, KAREN MILDRED
POWELL as described in Count I above, Plaintiff, JANICE SWANK, suffered bodily injury
and resulting pain and suffering, disability, disfigurement, mental anguish, loss of capacity
for the enjoyment of life, expense of hospitalization, medical and nursing care and treatment,
loss of earnings, loss of ability to earn money, and/or aggravation of a previously existing
condition. The losses are either permanent or continuing and the Plaintiff will suffer the losses
in the future.
12. This claim arises under the uninsured/underinsured motorist provision(s) of a
policy of insurance issued by Defendant, AUTO CLUB INSURANCE COMPANY OF
FLORIDA, in favor of Plaintiff, JANICE SWANK, as a passenger in the insured vehicle,
being operated by Donna Raposa, which was in full force and effect with the Defendant,
AUTO CLUB INSURANCE COMPANY OF FLORIDA, on April 02, 2023, with the policy
number of FHP0037152. A certified copy of the insurance policy declarations page is attached
hereto as Plaintiffs’ Exhibit “A” and is fully incorporated herein by reference.
13. Plaintiff, JANICE SWANK, has fully complied with the terms and conditions
insurance policy issued by Defendant AUTO CLUB INSURANCE COMPANY OF
FLORIDA, and all conditions precedent have been performed, been waived, or have
occurred.
14. Plaintiff, JANICE SWANK, has submitted to Defendant, AUTO CLUB
INSURANCE COMPANY OF FLORIDA, a claim and demand for payment of
underinsured motorist benefits in compliance with the claim procedures and requirements set
forth in the insurance policy issued by Defendant AUTO CLUB INSURANCE COMPANY
OF FLORIDA.
15. Following the above-described motor vehicle collision, Defendant AUTO
CLUB INSURANCE COMPANY OF FLORIDA has refused and continues to refuse to
adequately compensate Plaintiff JANICE SWANK.
WHEREFORE, Plaintiff, JANICE SWANK, demands judgment against the
Defendant, AUTO CLUB INSURANCE COMPANY OF FLORIDA, for damages in excess
of Fifty Thousand One Dollars ($50,001.00), exclusive of interest, attorney’s fees, and costs,
and the Plaintiff demands a trial by jury.
RUE & ZIFFRA
Wal Ax
Allan L. Ziffra, Esquire
632 Dunlawton Avenue
Port Orange, FL 32127
Phone: (386) 788-7700
FBN: 0749265
Email: aziffra@rueziffra.com
joanneh@rueziffra.com
Attorney for the Plaintiff
PO Box 31107, Tampa, FL 33631
Auto Club Insurance Florida Package Policy Amended Declaration
Company of Florida
Supersedes any Previous Declaration Bearing the Same Number for this Policy Period
Policy Premium: $2,938.36
Policy #: FHP0037152 Effective Date: 07/26/2022 Expiration Date: 07/26/2023 12:01 A.M. Eastern Time
Reason for Change: Effective Date of Change: Amount of Increase:
Change Amendment 09/08/2022 $0.00
Named Insured(s): DONNA RAPOSA Agent: ACG SOUTH INSURANCE AGENCY, LLC
139 PINE GROVE DR 2525 INTERNATIONAL SPEEDWAY BL
PALM COAST FL 32164-7034 DAYTONA BEACH FL 32114
800-289-1325
First Mortgagee:
NATIONSTAR MORTGAGE LLC ISAOA
PO BOX 7729
SPRINGFIELD OH 45501-7729
Account #: 0637603762
AAA Membership #: 182672110 Year Joined: 1993 Payment Option:
Homeowners Coverage Information
PART | PROPERTY COVERAGES LIMIT OF LIABILITY PREMIUM
A - DWELLING $440,220 $1,898.00
B - OTHER STRUCTURES $44,022 Included
C - PERSONAL PROPERTY $110,055 Included
D -LOSS OF USE $44,022 Included
LIMITED WATER DAMAGE - SPECIAL LIMIT $10,000 Included
PART Il PERSONAL LIABILITY COVERAGES
E - PERSONAL LIABILITY $500,000 $28.00
F - MEDICAL PAYMENTS TO OTHERS $5,000 $11.00
ADDITIONAL COVERAGE
Sinkhole Coverage Included Included
Personal Property Replacement Cost Yes Included
Extended Replacement Cost Coverage 25% Yes Included
Identity Fraud Coverage Yes $24.00
Loss Assessment Coverage $1,000 $8.00
Ordinance or Law Coverage 5% $110,055 Included
Screened Enclosure Wind Buyback $5,000 $99.00
Mold, Fungus, Wet Rot, Dry Rot, Or Bacteria $10,000 Included
Alarm or Fire Protection Coverage Yes Included
Windstorm and Hurricane Mitigation Coverage Yes Included
FEES & ASSESSMENTS
FHCF Regular Assessment (Dwelling) Included
Florida Insurance Guaranty Association Assessment $41.36
Citizens PLA Regular Assessment Included
Emergency Management Preparedness And Assistance Trust Fund $2.00
FL 3000 0921 Page 1 of 6
EXHIBIT A
Named Insured(s) Effective Date Expiration Date Policy #
DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152
ALL OTHER PERILS DEDUCTIBLE: $1,000
SINKHOLE DEDUCTIBLE: $1,000
HURRICANE DEDUCTIBLE: 2% $8,804
TOTAL PREMIUM NON-HURRICANE HOMEOWNER COVERAGE: $1,505.00
TOTAL PREMIUM HURRICANE HOMEOWNER COVERAGE: $563.00
TOTAL PREMIUM HOMEOWNER FEES: $43.36
TOTAL PREMIUM HOMEOWNER COVERAGE: $2,111.36
FL 3000 0921 Page 2 of 6
Named Insured(s) Effective Date Expiration Date Policy #
DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152
Auto Coverage Informatio! LIMIT OF LIABILITY PREMIUM
PER VEH# 5
PERSON/OCCURRENCE 2020/VOLK
BODILY INJURY 100,000/300,000 $323.00
PROPERTY DAMAGE 100,000 $106.00
MEDICAL PAYMENTS No Coverage
UNINSURED MOTORIST No Coverage
PERSONAL INJURY PROTECTION 10,000 $72.00
OTHER THAN COLLISION DEDUCTIBLE VEHICLE(S) $109.00
#5 250
COLLISION DEDUCTIBLE VEHICLE(S) $187.00
#5 500
RENTAL REIMBURSEMENT $30.00
#5 30/900
ADDITIONAL COVERAGES
Collision Deductible Waiver Included
VEHICLE TOTAL $827.00
TOTAL PREMIUM AUTO COVERAGE: $827.00
TOTAL PREMIUM AUTO FEES: $0.00
TOTAL POLICY PREMIUM: $2,938.36
FL 3000 0921 Page 3 of 6
Named Insured(s) Effective Date Expiration Date Policy #
DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152
Residence Premises: Sq. Ft. Yr. Built Const. Type
139 PINE GROVE DR PALM COAST FL 32164-7034 2286 2005 Reinforced
Masonry
Vehicle Information
No. Year Make Model Vehicle ID #
#5 2020 VOLKSWAGEN TIGUAN SE/SE R-LINE BLACK 3VV3B7AX6LM 137393
Discounts: AirBag $2.00, Anti-Lock $16.00, Anti-Theft $3.00, Education Occupation $39.00
Usage: Pleasure Annual Mileage: 6000
Lienholder: VOLKSWAGEN BANK USA
Unless otherwise stated, all insured vehicles are garaged at the named insured's residence.
Household Driver License
Resident No. Name D.O.B Status Vehicle # Prin/Occ
3 DONNA RAPOSA 01/25/1966 Active 5 Pp
Policy Discounts: AAA Membership, Payment Plan, Senior Discount, Same Prior Carrier, Hip Roof, Burglar Alarm, Fire
Alarm, Package Policy
Applicable Forms and Endorsements:
Outline of Coverage Section II Personal Auto Cov Form - FLPPA00181107
Medical Fee Schedule for PIP Claims - FLIN20000113
Personal Injury Protection Coverage - FLPPA00220113
Personal Injury Protection Outline Form - FLPPA00140113
Identity Fraud Expense Coverage Endorsement - FLHO00550107
Deductible Notice - FLHO00120107
Premium Discount for Hurricane Loss Mitigation - FLHO00020410
Collision Deductible Waiver Endorsement - FLPPA00050107
Homeowners Form 3 and Personal Automobile Package Policy - FL10001007
Outline of Coverage Section | Homeowners Coverages Form - FLHO00091007
Screened Enclosures Windstorm or Hurricane Windstorm End - FLHO00490107
Building Ordinance or Law Endorsement (HO-3) - FLHO02571007
Sinkhole Coverage Endorsement (HO-3) - FLHO03630712
Corporate Signatures - FL1000a1015
Loss Assessment Coverage Endorsement - FLHO00350107
Extended Replacement Cost Endorsement - FLHO02801007
Personal Property Replacement Cost Endorsement (HO-3) - FLHO02900107
Package Policy Blanket Deductible Amendatory Endorsement (HO3) - FL15000122
Catastrophic Ground Cover Collapse Endorsement (HO-3) - FLHO03730712
Alarm Or Fire Protection System End. - FLHO02160107
Premise Alarm Fire Protection Systems - FLHO00040107
Limited Water Damage Coverage Endorsement (HO-3) - FLHO04310921
Package Declarations - FL30000921
FL 3000 0921 Page 4 of 6
Named Insured(s) Effective Date Expiration Date Policy #
DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152
If you have questions regarding your coverage or need to report a claim please call:
AUTO CLUB INSURANCE COMPANY OF FLORIDA: -888-929-4222
AUTHORIZED COUNTERSIGNATURE DATE
Ahiyg
A oe 09/09/2022
Gregg Olivanti
FL 3000 0921 Page 5 of 6
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Filing # 194435789 E-Filed 03/20/2024 01:42:01 PM IN THE CIRCUIT COURT FOR THE SEVENTH JUDICIAL CIRCUIT, IN AND FOR FLAGLER COUNTY, FLORIDA CASE NO.: 2024 CA 000071 DIVISION: 49 JANICE SWANK, Plaintiff, vs. KAREN MILDRED POWELL and AUTO CLUB INSURANCE COMPANY OF FLORIDA, a Florida Profit Corporation Defendant. / AMENDED COMPLAINT COMES NOW Plaintiff, JANICE SWANK, by and through the undersigned counsel, and hereby sues Defendants, KAREN MILDRED POWELL and AUTO CLUB INSURANCE COMPANY OF FLORIDA, a Florida Profit Corporation, and alleges as follows: 1 This is an action for damages in excess of Fifty Thousand and One Dollars ($50,001.00), exclusive of interest, attorneys’ fees, and costs (the estimated value of Plaintiffs claim is in excess of the minimum jurisdictional threshold required by this Court). Accordingly, Plaintiff entered “$50,001.00” on the Civil Cover Sheet for the “estimated amount of the claim,” as required in the preamble to the Civil Cover Sheet, for jurisdictional purposes only (the Florida Supreme Court has ordered that the estimated “amount of claim” be set forth in the Civil Cover Sheet for data collection and clerical purposes only). The actual value of the Plaintiff's claim will be determined by a fair and just jury in accordance with Article 1, Section 21, Fla. Const. 2 At all times material hereto, Plaintiff, JANICE SWANK, was a resident of Palm Coast, Flagler County, Florida. Electronically Received in the Office of the Clerk of the Circuit Court - Flagler County, Florida - 03/20/2024 02:57 PM - DIN: 16 3 At all times material hereto, Defendant, KAREN MILDRED POWELL, was a resident of Daytona Beach, Volusia County, Florida. 4 At all times material hereto, Defendant AUTO CLUB INSURANCE COMPANY OF FLORIDA was a Florida Profit Corporation licensed and doing business in the State of Florida. 5 The motor vehicle collision, which is the basis of this action, occurred in Palm Coast, Flagler County, Florida. COUNT I - PLAINTIFF’S LIABILITY CLAIM AGAINST DEFENDANT, KAREN MILDRED POWELL 6 Plaintiff realleges and incorporates by reference paragraphs one (1) through five (5), and further states: 7 On or about April 2, 2023, Plaintiff, JANICE SWANK, was a passenger in a 2020 Volkswagen motor vehicle that was owned and operated by Donna Raposa and was stopped for a red traffic light at Town Center Boulevard in Palm Coast, Flagler County, Florida. 8 On or about April 2, 2023, Defendant, KAREN MILDRED POWELL, was the owner and operator of a 2016 Jeep motor vehicle. 9. At the above-stated time and place, Defendant, KAREN MILDRED POWELL, negligently owned, operated, and/or maintained her vehicle in such a way as to cause a collision with the motor vehicle that Plaintiff, JANICE SWANK was a passenger in. 10. As a result of the negligence of Defendant, KAREN MILDRED POWELL, as set forth hereinabove, Plaintiff JANICE SWANK, suffered bodily injury and resulting pain and suffering, disability, disfigurement, mental anguish, loss of capacity for the enjoyment of life, expense of hospitalization, medical and nursing care and treatment, loss of earnings, loss of ability to earn money, and/or aggravation of a previously existing condition. The losses are either permanent or continuing and the Plaintiff will suffer the losses in the future. WHEREFORE, Plaintiff, JANICE SWANK, demands judgment against the Defendant, KAREN MILDRED POWELL, for damages in excess of Fifty Thousand One Dollars ($50,001.00), exclusive of interest, attorney’s fees, and costs, and the Plaintiff demands a trial by jury. COUNT I - PLAINTIFF’S CLAIM OF NEGLIGENCE AS TO DEFENDANT, AUTO CLUB INSURANCE COMPANY OF FLORIDA Plaintiff realleges and incorporates by reference paragraphs one (1) through ten (10), and further states: 11. As a result of the negligence of underinsured Defendant, KAREN MILDRED POWELL as described in Count I above, Plaintiff, JANICE SWANK, suffered bodily injury and resulting pain and suffering, disability, disfigurement, mental anguish, loss of capacity for the enjoyment of life, expense of hospitalization, medical and nursing care and treatment, loss of earnings, loss of ability to earn money, and/or aggravation of a previously existing condition. The losses are either permanent or continuing and the Plaintiff will suffer the losses in the future. 12. This claim arises under the uninsured/underinsured motorist provision(s) of a policy of insurance issued by Defendant, AUTO CLUB INSURANCE COMPANY OF FLORIDA, in favor of Plaintiff, JANICE SWANK, as a passenger in the insured vehicle, being operated by Donna Raposa, which was in full force and effect with the Defendant, AUTO CLUB INSURANCE COMPANY OF FLORIDA, on April 02, 2023, with the policy number of FHP0037152. A certified copy of the insurance policy declarations page is attached hereto as Plaintiffs’ Exhibit “A” and is fully incorporated herein by reference. 13. Plaintiff, JANICE SWANK, has fully complied with the terms and conditions insurance policy issued by Defendant AUTO CLUB INSURANCE COMPANY OF FLORIDA, and all conditions precedent have been performed, been waived, or have occurred. 14. Plaintiff, JANICE SWANK, has submitted to Defendant, AUTO CLUB INSURANCE COMPANY OF FLORIDA, a claim and demand for payment of underinsured motorist benefits in compliance with the claim procedures and requirements set forth in the insurance policy issued by Defendant AUTO CLUB INSURANCE COMPANY OF FLORIDA. 15. Following the above-described motor vehicle collision, Defendant AUTO CLUB INSURANCE COMPANY OF FLORIDA has refused and continues to refuse to adequately compensate Plaintiff JANICE SWANK. WHEREFORE, Plaintiff, JANICE SWANK, demands judgment against the Defendant, AUTO CLUB INSURANCE COMPANY OF FLORIDA, for damages in excess of Fifty Thousand One Dollars ($50,001.00), exclusive of interest, attorney’s fees, and costs, and the Plaintiff demands a trial by jury. RUE & ZIFFRA Wal Ax Allan L. Ziffra, Esquire 632 Dunlawton Avenue Port Orange, FL 32127 Phone: (386) 788-7700 FBN: 0749265 Email: aziffra@rueziffra.com joanneh@rueziffra.com Attorney for the Plaintiff PO Box 31107, Tampa, FL 33631 Auto Club Insurance Florida Package Policy Amended Declaration Company of Florida Supersedes any Previous Declaration Bearing the Same Number for this Policy Period Policy Premium: $2,938.36 Policy #: FHP0037152 Effective Date: 07/26/2022 Expiration Date: 07/26/2023 12:01 A.M. Eastern Time Reason for Change: Effective Date of Change: Amount of Increase: Change Amendment 09/08/2022 $0.00 Named Insured(s): DONNA RAPOSA Agent: ACG SOUTH INSURANCE AGENCY, LLC 139 PINE GROVE DR 2525 INTERNATIONAL SPEEDWAY BL PALM COAST FL 32164-7034 DAYTONA BEACH FL 32114 800-289-1325 First Mortgagee: NATIONSTAR MORTGAGE LLC ISAOA PO BOX 7729 SPRINGFIELD OH 45501-7729 Account #: 0637603762 AAA Membership #: 182672110 Year Joined: 1993 Payment Option: Homeowners Coverage Information PART | PROPERTY COVERAGES LIMIT OF LIABILITY PREMIUM A - DWELLING $440,220 $1,898.00 B - OTHER STRUCTURES $44,022 Included C - PERSONAL PROPERTY $110,055 Included D -LOSS OF USE $44,022 Included LIMITED WATER DAMAGE - SPECIAL LIMIT $10,000 Included PART Il PERSONAL LIABILITY COVERAGES E - PERSONAL LIABILITY $500,000 $28.00 F - MEDICAL PAYMENTS TO OTHERS $5,000 $11.00 ADDITIONAL COVERAGE Sinkhole Coverage Included Included Personal Property Replacement Cost Yes Included Extended Replacement Cost Coverage 25% Yes Included Identity Fraud Coverage Yes $24.00 Loss Assessment Coverage $1,000 $8.00 Ordinance or Law Coverage 5% $110,055 Included Screened Enclosure Wind Buyback $5,000 $99.00 Mold, Fungus, Wet Rot, Dry Rot, Or Bacteria $10,000 Included Alarm or Fire Protection Coverage Yes Included Windstorm and Hurricane Mitigation Coverage Yes Included FEES & ASSESSMENTS FHCF Regular Assessment (Dwelling) Included Florida Insurance Guaranty Association Assessment $41.36 Citizens PLA Regular Assessment Included Emergency Management Preparedness And Assistance Trust Fund $2.00 FL 3000 0921 Page 1 of 6 EXHIBIT A Named Insured(s) Effective Date Expiration Date Policy # DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152 ALL OTHER PERILS DEDUCTIBLE: $1,000 SINKHOLE DEDUCTIBLE: $1,000 HURRICANE DEDUCTIBLE: 2% $8,804 TOTAL PREMIUM NON-HURRICANE HOMEOWNER COVERAGE: $1,505.00 TOTAL PREMIUM HURRICANE HOMEOWNER COVERAGE: $563.00 TOTAL PREMIUM HOMEOWNER FEES: $43.36 TOTAL PREMIUM HOMEOWNER COVERAGE: $2,111.36 FL 3000 0921 Page 2 of 6 Named Insured(s) Effective Date Expiration Date Policy # DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152 Auto Coverage Informatio! LIMIT OF LIABILITY PREMIUM PER VEH# 5 PERSON/OCCURRENCE 2020/VOLK BODILY INJURY 100,000/300,000 $323.00 PROPERTY DAMAGE 100,000 $106.00 MEDICAL PAYMENTS No Coverage UNINSURED MOTORIST No Coverage PERSONAL INJURY PROTECTION 10,000 $72.00 OTHER THAN COLLISION DEDUCTIBLE VEHICLE(S) $109.00 #5 250 COLLISION DEDUCTIBLE VEHICLE(S) $187.00 #5 500 RENTAL REIMBURSEMENT $30.00 #5 30/900 ADDITIONAL COVERAGES Collision Deductible Waiver Included VEHICLE TOTAL $827.00 TOTAL PREMIUM AUTO COVERAGE: $827.00 TOTAL PREMIUM AUTO FEES: $0.00 TOTAL POLICY PREMIUM: $2,938.36 FL 3000 0921 Page 3 of 6 Named Insured(s) Effective Date Expiration Date Policy # DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152 Residence Premises: Sq. Ft. Yr. Built Const. Type 139 PINE GROVE DR PALM COAST FL 32164-7034 2286 2005 Reinforced Masonry Vehicle Information No. Year Make Model Vehicle ID # #5 2020 VOLKSWAGEN TIGUAN SE/SE R-LINE BLACK 3VV3B7AX6LM 137393 Discounts: AirBag $2.00, Anti-Lock $16.00, Anti-Theft $3.00, Education Occupation $39.00 Usage: Pleasure Annual Mileage: 6000 Lienholder: VOLKSWAGEN BANK USA Unless otherwise stated, all insured vehicles are garaged at the named insured's residence. Household Driver License Resident No. Name D.O.B Status Vehicle # Prin/Occ 3 DONNA RAPOSA 01/25/1966 Active 5 Pp Policy Discounts: AAA Membership, Payment Plan, Senior Discount, Same Prior Carrier, Hip Roof, Burglar Alarm, Fire Alarm, Package Policy Applicable Forms and Endorsements: Outline of Coverage Section II Personal Auto Cov Form - FLPPA00181107 Medical Fee Schedule for PIP Claims - FLIN20000113 Personal Injury Protection Coverage - FLPPA00220113 Personal Injury Protection Outline Form - FLPPA00140113 Identity Fraud Expense Coverage Endorsement - FLHO00550107 Deductible Notice - FLHO00120107 Premium Discount for Hurricane Loss Mitigation - FLHO00020410 Collision Deductible Waiver Endorsement - FLPPA00050107 Homeowners Form 3 and Personal Automobile Package Policy - FL10001007 Outline of Coverage Section | Homeowners Coverages Form - FLHO00091007 Screened Enclosures Windstorm or Hurricane Windstorm End - FLHO00490107 Building Ordinance or Law Endorsement (HO-3) - FLHO02571007 Sinkhole Coverage Endorsement (HO-3) - FLHO03630712 Corporate Signatures - FL1000a1015 Loss Assessment Coverage Endorsement - FLHO00350107 Extended Replacement Cost Endorsement - FLHO02801007 Personal Property Replacement Cost Endorsement (HO-3) - FLHO02900107 Package Policy Blanket Deductible Amendatory Endorsement (HO3) - FL15000122 Catastrophic Ground Cover Collapse Endorsement (HO-3) - FLHO03730712 Alarm Or Fire Protection System End. - FLHO02160107 Premise Alarm Fire Protection Systems - FLHO00040107 Limited Water Damage Coverage Endorsement (HO-3) - FLHO04310921 Package Declarations - FL30000921 FL 3000 0921 Page 4 of 6 Named Insured(s) Effective Date Expiration Date Policy # DONNA RAPOSA 07/26/2022 07/26/2023 FHP0037152 If you have questions regarding your coverage or need to report a claim please call: AUTO CLUB INSURANCE COMPANY OF FLORIDA: -888-929-4222 AUTHORIZED COUNTERSIGNATURE DATE Ahiyg A oe 09/09/2022 Gregg Olivanti FL 3000 0921 Page 5 of 6