Preview
WV
iD: QU OUN PK Yd Oo: INDEX NO. 709796/2024
NYSCEF BOC. NO. 4 RECEIVED NYSCEF: 05/08/2024
Exhibit B
PK 09 WV INDEX NO. 709796/2024
) QU OUN 08
NYSCEF BOC. NO. 4 RECEIVED NYSCEF: 05/08/2024
S® StateFarm
Certified Policy Record
I, the undersigned, do hereby confirm that | am custodian of the records pertaining to the issuance of
policies by State Farm Indemnity Company.
| certify that the attached documents represent a true and accurate record of the terms and
conditions of Policy Number OB including any endorsements, if applicable, for the
policy term(s) 02/28/2023 TO 06/21/2023 and insuring ESPINAL, FRANCISCO & SOTO SINDIA
based on available records.
It is State Farm's business practice to print a new Declarations Page only when a policy issuance
transaction such as a change of coverage occurs. Therefore, the included Declarations Page which
was in effect at the time of loss will indicate the policy period of the last policy issuance transaction.
The policy was in effect on the loss date of 03/13/2023.
wnl/a,—
Jessica ®ass
Underwriter
Date: 04/20/2024
Page 1 of
1011493 2000 157822 200 02-09-2022
D: PK oO. WV INDEX NO. 709796/2024
OL iy det CUTTYpany Yd INDM_VOL
NYSCEF DOCRo Mé&x.23
Be HO 236s, IL 61702-2358 DECLARATIONS PAGE
= !VED NYSCEF 05/08/2024
PAGE 1 OF 2
NAMED INSURED
T
001693 0058.
POLICY NUMBER oeeee°°
ESPINAL, FRANCISCO & SOTO POLICY PERIOD FEB 08 2023 to FEB 28 2023
SINDIA 12:01 AM. Standard Tine
696 LEE H
UNION NJ 07083-7615 STATE FARM PAYMENT PLAN NUMBER
1335705517,
AGENT
hh OME ot tal Laveee tee LLL ha MARIA ALAW!
as
ge 789 HAMBURG TPKE
88 WAYNE, NJ 07470-8416
oe
PHONE: (862)221-9707
DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSE D.
YOUR CAR
SHIGLE VEAR MAKE wopel"/BobyStvie”“VenicLeip.NumBeR
|] [7 etass 7]
1 2006 __ HONDA ODYSSEY VAN SFNRL38626B413492 20FF1W1500
2 2000 JEEP GR CHEROKE SPORT WG 1d4GW48S8YC127142 20FH1W1500
3 2006 __ ACURA MDX. SPORT WG 2HNYD18226H549362 103H1W1500
[ae oo
2006 2000 2006
AC
Boat injutsea
tba Cove
mma a
“eaePerson, Each Accident
"$100,000 a
Se.c0p
erty Dar e Limit
Ea ehAe id a
$25,000
©Personal Injury Protection oa oa a a
“Ss Policy Schedule for Coverage Descriptior
ledic Bei ts Lin $1 oe a a oa
Eme enc, Road Server Co}
inin:
canbe inj Limits
iderinsur Le ED a
32
oF
29
7 a a
oe ers Eso Aceidnbtcmieusomlmmsom Css
a cieteocanone a
$50,000 $100,000
"Property Damag
jamage Limit pce Css
a cieteocanone a
Each Accident
$21 Sissies
a cietocaoun poceien
I Total Premium Per Vehicle $50-76 4-19 $67.04
[Ep Notalipromiuin for FEB 08 2027 toFEB 2820250 hserovabil
CONTINUED
03039/01560 See Reverse Side
nixon598,(era0 007 (ote025)
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024
This policy is issued by State Farm Indemnity Company.
Participating Policy
You are entitled to participate in a distribution of the earnings of the company as determined by
our Board of Directors in accordance with the Company's Articles of Incorporation, as amended.
In Witness Whereof, the State Farm Indemnity Company has caused this policy to be signed by
its President and Secretary at Bloomington, Illinois.
Herne Yat Chai Schl
Secretary President
810
OL] NWSaekAQU ANLT.Ypany PK 19 WV
INDM_VOL
INDEX NO. 709796/2024
NYSCEF DOCro Néx.2348 DECLARATIONS PAGE
©! VED \YSCEF 05/08/2024
Bloomington IL 61702-2358
PAGE 2 OF 2
POLICY NUMBER a
NAMED INSURED 091693 0058
ES INAL, FRANC TSC
Isc ‘0 & SOTO POLICY PERIOD FEB 08 2023 to FEB 28 2023
SINDIA 12:01 AM. Standard Time
696
UNION NJ 07083-76 55 STATE FARM PAYMENT PLAN NUMBER
1335705517,
as
ge
88
os
gS
be
os
i i
Years in fi ee
ess remjer
ess than remier
103 Less than re
Replaced policy number 1509552-30A.
Your total renewal remium for AUG 31 2022 to FEB 28 2023 is $1,459.23,
Vehicle 1 $457.25, /ehicle 2 $398.01, Vehicle 3 $603.97.
See insert for explanation of class plan
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.
Your premium was determined by the information on drivers, driving records, and other information you provided, as well
as consumer report information, includin ‘Average number of months since bank revolving accounts established; Total
number of claims in the last 60 months; jumber of inquiries for transactions initiated by consumer in the last 6 months.
Consumer report reference numbers: 23039171203972, HO8J5PD, 15550891U363690
Credit information was obtained on: SINDIA SOTO
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 coul resullt in a lower rate, no change in rate, or a higher rate.
Please refer to the enclosed insert for additional information.
Notice of insurance information collection practices -
We often collect ersonal information from persons other
Such personal in fejo. mation may, in certain circumstances,
fibeersonal , family, or household insurance transactions:
an the individual or individuals listed on the policy.
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.
policy book
i ih adda RES BRUM nl ER El 10 ve
ake, MENRATRRY ERRORSERNT-
LIMITATION ON LAWSUIT OPTION.
Agent: MARIA ALAW!
Telephone: (862)221-9707
03040/01560 {ora02s4e) Prepared APR 21 2023 095C-B28
rane355-3886-3(o1a025¥d)
08-2007 (ota02Sle)
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024
This policy is issued by State Farm Indemnity Company.
Participating Policy
You are entitled to participate in a distribution of the earnings of the company as determined by
our Board of Directors in accordance with the Company's Articles of Incorporation, as amended.
In Witness Whereof, the State Farm Indemnity Company has caused this policy to be signed by
its President and Secretary at Bloomington, Illinois.
Herne Yat Chai Schl
Secretary President
810
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024
6128CB AMENDATORY ENDORSEMENT
This endorsement is a part of the policy. Except for the changes this endorsement makes, all other
provisions of the policy remain the same and apply to this endorsement.
1 DEFINITIONS b. neither available for, nor being
used for, carrying persons for a
Newly Acquired Car is changed to read:
charge.
Newly Acquired Car means a car newly b. Exclusions
owned by you or a resident relative.
(1) Exclusion 5. is changed to read:
A car ceases to be a newly acquired car
on the earlier of: THERE IS NO COVERAGE
FOR AN INSURED FOR DAM-
1 the effective date and time of a pol- AGES ARISING OUT OF THE
icy, including any binder, issued by OWNERSHIP, MAINTE-
us or any other company that de- NANCE, OR USE OF A VEHI-
scribes the car as an insured vehicle;
CLE WHILE IT IS:
or
a. MADE AVAILABLE; OR
the end of the 14th calendar day im-
mediately following the date the car b. BEING USED
is delivered to you or a resident rel- TO CARRY PERSONS FOR A
ative. CHARGE. This exclusion does
The broadest coverage provided by this not apply to the use of a private
policy for any car shown on the Decla- passenger car on a share-the-
rations Page under “YOUR CAR” will expense basis;
apply to a newly acquired car. (2) The language in exclusion 6. that
2. LIABILITY COVERAGE reads:
a. Additional Definition This exclusion does not apply to
damage to a:
Item 4. of Insured is changed to read:
a. motor vehicle owned by the
Insured means any other person or employer of you or any res-
organization vicariously liable for the ident relative if such dam-
use of a vehicle by an insured as de- age is caused by an insured
fined in 1., 2., or 3. above, but only
while operating another
for such vicarious liability. This motor vehicle;
provision applies only if the vehicle
is: residence while rented to or
leased to an insured; or
a. neither owned by, nor hired by,
that other person or organiza- private garage while rented
tion; and to or leased to an insured;
Page
| of 5 357-6128CB
©, Copyright, State Farm Mutual Automobile Insurance Company, 2015
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024
is changed to read: is changed to read:
This exclusion does not apply to Deductible
damage to a: 1 A Comprehensive Coverage de-
a. motor vehicle owned by the ductible applies to those vehi-
employer of you or the em-
cles for which a deductible and
a corresponding coverage sym-
ployer of any resident rela-
bol and premium are shown on
tive if such damage is the Declarations Page.
caused by an insured while
operating another motor ve- A Collision Coverage deducti-
hicle; ble applies to those vehicles for
which a deductible and a corre-
residence while rented to or sponding coverage symbol and
leased to an insured; or premium are shown on the Dec-
private garage while rented larations Page.
to or leased to an insured; Insuring Agreements
3. MEDICAL PAYMENTS COVERAGE Car Rental and Travel Expenses Cov-
erage
Exclusions
Item 4.a. Car Rental Expense is
Exclusion 4. is changed to read: changed to read:
THERE IS NO COVERAGE FOR AN Car Rental Expense
INSURED WHO IS OCCUPYING A
VEHICLE WHILE IT IS: We will pay the daily rental charge
incurred when an insured rents a car
a. MADE AVAILABLE; OR
from a car business while your car
b. BEING USED or a newly acquired car is:
TO CARRY PERSONS FOR A (1) not drivable; or
CHARGE. This exclusion does not ap- (2) being repaired
ply to:
as a result of a loss which would be
a. the use of a private passenger car on payable under Comprehensive Cov-
a share-the-expense basis; or
erage or Collision Coverage.
b. an insured while occupying a non-
We will pay this daily rental charge
owned car as a passenger; incurred during a period that:
4. PHYSICAL DAMAGE COVERAGES
(1) starts on the date:
a. The paragraph that reads: (a) the vehicle is not drivable as
If a deductible applies to Compre- a result of the loss; or
hensive Coverage, then it is shown (b) the vehicle is left at a repair
on the Declarations Page for the ve- facility if the vehicle is driv-
hicles to which it applies. The de- able; and
ductible that applies to Collision
Coverage is shown on the Declara- (2) ends on the earliest of:
tions Page for the vehicles to which (a) the date the vehicle has been
it applies. repaired or replaced;
Page 2 of 5 357-6128CB
©, Copyright, State Farm Mutual Automobile Insurance Company, 2015
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024
(b) the date we offer to pay for information we deem neces-
the Joss if the vehicle is re- sary to substantiate the
pairable but you choose to claim.
delay repairs; or Such authorizations must
(c) seven days after we offer to not:
pay for the Joss if the vehi- (a) restrict us from per-
cle is: forming our business
(i) a total loss as deter- functions in:
mined by us; or
(i) obtaining records,
(ii) stolen and not recov- bills, information,
ered. and data; nor
The amount of any such daily rental (ii) using or retaining
charge incurred by an insured must records, bills, infor-
be reported to us before we will pay mation, and data
such amount. collected or re-
ceived by us;
c. Exclusions
(b) require us to violate
Exclusion 3. is changed to read: federal or state laws or
THERE IS NO COVERAGE FOR regulations;
ANY | COVERED VEHICLE (©) prevent us from ful-
WHILE IT IS: filling our data report-
a. MADE AVAILABLE; OR ing and data retention
obligations to insurance
b. BEING USED regulators; or
TO CARRY PERSONS FOR A (d) prevent us from dis-
CHARGE. This exclusion does not closing claim infor-
apply to the use of a private passenger mation and data:
car on a share-the-expense basis; (i) to enable perfor-
5 INSURED’S DUTIES mance of our busi-
ness functions;
a. Ttem 6.b.(3) is changed to read:
(ii) to meet our report-
A person making claim under: ing obligations to
b. Medical Payments Coverage, insurance regula-
Uninsured and Underinsured tors;
Motorist Coverage, or Death,
(iii)to meet our report-
Dismemberment and Loss of ing obligations to
Sight Coverage must: insurance data con-
(3) provide written authoriza- solidators; and
tion for us to obtain medical (iv)as otherwise per-
bills, medical records, wage
mitted by law.
information, salary infor-
mation, employment infor- If an injured insured is a
mation, and any other minor, unable to act, or
Page 3 of 5 357-6128CB
©, Copyright, State Farm Mutual Automobile Insurance Company, 2015
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024
dead, then his or her legal any document or notice, including a
representative must provide notice to renew, nonrenew, or can-
us with the written authori- cel, instead of mailing it or deliver-
zation. ing it by other means. Proof of
If the holder of the infor- transmission will be sufficient proof
mation refuses to provide of notice.
it to us despite the authori- Our Rights Regarding Claim In-
zation, then at our request formation
the person making claim or a We will collect, receive, obtain,
his or her legal representative use, and retain all the items de-
must obtain the information scribed in item b.(1) below and
and promptly provide it to use and retain the information
us; and
described in item b.(3)(b) be-
b. The following is added to item 6.: low, in accordance with applica-
A person making claim under Med- ble federal and state laws and
ical Payments Coverage, Uninsured regulations and consistent with
the performance of our business
and Underinsured Motorist Cover-
functions.
age, or Death, Dismemberment and
Loss of Sight Coverage must submit Subject to a. above, we will not
to us all information we need to be restricted in or prohibited
comply with federal and state laws from:
and regulations.
(1) collecting, receiving, or ob-
6. GENERAL TERMS taining records, receipts, in-
a. The following is added to Newly voices, medical bills,
Owned or Newly Leased Car: medical records, wage infor-
mation, salary information,
Ifa resident relative wants to insure
a car newly owned by the resident employment information,
relative with the State Farm Com- data, and any other infor-
panies after that car ceases to be a mation;
newly acquired car, then the resi- (2) sing any of the items de-
dent relative must apply to the State scribed in item b.(1) above;
Farm Companies for a separate pol- or
icy to insure the car newly owned by
the resident relative. Such policy (3) retaining:
will be issued only if both the appli- (a) any of the items in item
cant and the vehicle are eligible for b.(1) above; or
coverage at the time of the applica-
tion. (b) any other information
we have in our posses-
b. The following are added to GENERAL sion as a result of our
TERMS:
processing, handling,
Electronic Delivery or otherwise resolving
With your consent, we may, if al- claims submitted under
lowed by law, electronically deliver this policy.
Page 4 of 5 357-6128CB
©, Copyright, State Farm Mutual Automobile Insurance Company, 2015
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024
c. We may disclose any of the (4) to meet other obligations re-
items in item b.(1) above and quired by law; and
any of the information de- (5) as otherwise permitted by law.
scribed in item b.(3)(b) above: Our rights under a., b., and c.
(1) to enable performance of above shall not be impaired by
our business functions; any:
(1) authorization related to any
(2) to meet our reporting obli-
claim submitted under this
gations to insurance regula- policy; or
tors;
(2) act or omission of an in-
(3) to meet our reporting obli- sured or a legal representa-
gations to insurance data tive acting on an insured’s
consolidators; behalf.
Page 5 of 5 357-6128CB
©, Copyright, State Farm Mutual Automobile Insurance Company, 2015
: INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024
Neen
S® StateFarm:
Neen
Please read the policy carefully. If there is an
accident, contact your State Farm agent or one
of our Claim Offices at once. (See “INSURED’S
DUTIES’ in this policy booklet.)
State Farm®
Standard Car Policy
Booklet
New Jersey
Policy Form 9630SA
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024
CONTENTS
THIS POLICY... If Other Medical Payments Coverage or
DEFINITIONS.... Similar Vehicle Insurance Applies. 24
Our Payment Options........... 25
LIABILITY COVERAGE
UNINSURED AND UNDERINSURED
Additional Definition MOTORIST COVERAGE.... 25
Insuring Agreement. Additional Definitions 25
Supplementary Payments. Insuring Agreement... 27
Limits... Notice of Tentative Settlement 27
Nonduplicatio Deciding Fault and Amount 28
Exclusions Limits . 28
If Other Liability Coverage Appli Nonduplication . 29
Required Out-of-State Liability Coverag: 10 Exclusions .... 29
Financial Responsibility Certification. 10 If Other Uninsured and Underinsured
Motorist Coverage or Other Insurance
PERSONAL INJURY PROTECTION Applies 30
COVERAGE... 10 Our Payment Options 31
Section A — Personal Injury Protection
PHYSICAL DAMAGE COVERAGES 31
Coverage ..... 10
Additional Definitions. 10 Additional Definitions 31
Exclusions.. 12 Insuring Agreements . 32
Limit of Liabilit 13 Supplementary Payments — Comprehen-
sive Coverage and Collision Coverage 34
Policy Perio 14
Limits and Loss Settlement — Compreher
Conditions 14 34
sive Coverage and Collision Coverage
Section B — Extended Medical Expense Limits — Car Rental and Travel Expenses
Benefits Coverage... 17 Coverage.
Additional Definitions. 17 Nonduplication 36
Exclusions 18 Exclusions .... 36
Conditions 18 If Other Physical Damage Coverage or
Limit of Liability 18 Similar Coverage Applie:
Section C — Premium Recomputation 19 Financed Vehicle .... 38
Schedule — Sections A and B. 19 New Jersey Mandatory Inspection
Coordination of Benefits... 20 Provision ... 39
Our Payment Options 39
MEDICAL PAYMENTS COVERAGE 21
Additional Definitions............ 21 DEATH, DISMEMBERMENT AND
LOSS OF SIGHT COVERAGE... 40
Insuring Agreement........ 22
Determining Medical Expens: 22 Additional Definition 40
Lim 22 Insuring Agreement... 40
Exclusions 23 Benefit . 40
9630SA
INDEX NO. 709796/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024
Exclusions...... 41 Where Coverage Applies 44
Our Payment Option 4l Newly Owned or Newly Leased Car. 44
INSURED’S DUTIES 42 Changes to This Policy. 44
Change of Residence. 45
Notice to Us of an Accident or Loss 42
Premium 45
Notice to Us of a Claim or Lawsuit 42
Renewal. 46
Insured’s Duty to Cooperate With Us 42
Nonrenewal 46
Questioning Under Oath... 42
Cancellatio: 46
Other Duties Under the Physical
Damage Coverages ..... . 42 Assignment 46
Other Duties Under Medical Payments Bankruptcy or Insolvency of the Insured 47
Coverage, Uninsured and Underinsured Concealment or Fraud 47
Motorist Coverage, and Death, Dismem- Our Right to Recover Our Payments. 47
berment and Loss of Sight Coverage 43 Legal Action Against Us ............ 47
GENERAL TERMS. 44 Choice of Law. 48
When Coverage App! 44 Severability... 48
THIS POLICY
This policy consists of: (1) The named insured shown on the
a. the most recently issued Declarations Declarations Page is the sole own-
Page;
Preview
WV iD: QU OUN PK Yd Oo: INDEX NO. 709796/2024 NYSCEF BOC. NO. 4 RECEIVED NYSCEF: 05/08/2024 Exhibit B PK 09 WV INDEX NO. 709796/2024 ) QU OUN 08 NYSCEF BOC. NO. 4 RECEIVED NYSCEF: 05/08/2024 S® StateFarm Certified Policy Record I, the undersigned, do hereby confirm that | am custodian of the records pertaining to the issuance of policies by State Farm Indemnity Company. | certify that the attached documents represent a true and accurate record of the terms and conditions of Policy Number OB including any endorsements, if applicable, for the policy term(s) 02/28/2023 TO 06/21/2023 and insuring ESPINAL, FRANCISCO & SOTO SINDIA based on available records. It is State Farm's business practice to print a new Declarations Page only when a policy issuance transaction such as a change of coverage occurs. Therefore, the included Declarations Page which was in effect at the time of loss will indicate the policy period of the last policy issuance transaction. The policy was in effect on the loss date of 03/13/2023. wnl/a,— Jessica ®ass Underwriter Date: 04/20/2024 Page 1 of 1011493 2000 157822 200 02-09-2022 D: PK oO. WV INDEX NO. 709796/2024 OL iy det CUTTYpany Yd INDM_VOL NYSCEF DOCRo Mé&x.23 Be HO 236s, IL 61702-2358 DECLARATIONS PAGE = !VED NYSCEF 05/08/2024 PAGE 1 OF 2 NAMED INSURED T 001693 0058. POLICY NUMBER oeeee°° ESPINAL, FRANCISCO & SOTO POLICY PERIOD FEB 08 2023 to FEB 28 2023 SINDIA 12:01 AM. Standard Tine 696 LEE H UNION NJ 07083-7615 STATE FARM PAYMENT PLAN NUMBER 1335705517, AGENT hh OME ot tal Laveee tee LLL ha MARIA ALAW! as ge 789 HAMBURG TPKE 88 WAYNE, NJ 07470-8416 oe PHONE: (862)221-9707 DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSE D. YOUR CAR SHIGLE VEAR MAKE wopel"/BobyStvie”“VenicLeip.NumBeR |] [7 etass 7] 1 2006 __ HONDA ODYSSEY VAN SFNRL38626B413492 20FF1W1500 2 2000 JEEP GR CHEROKE SPORT WG 1d4GW48S8YC127142 20FH1W1500 3 2006 __ ACURA MDX. SPORT WG 2HNYD18226H549362 103H1W1500 [ae oo 2006 2000 2006 AC Boat injutsea tba Cove mma a “eaePerson, Each Accident "$100,000 a Se.c0p erty Dar e Limit Ea ehAe id a $25,000 ©Personal Injury Protection oa oa a a “Ss Policy Schedule for Coverage Descriptior ledic Bei ts Lin $1 oe a a oa Eme enc, Road Server Co} inin: canbe inj Limits iderinsur Le ED a 32 oF 29 7 a a oe ers Eso Aceidnbtcmieusomlmmsom Css a cieteocanone a $50,000 $100,000 "Property Damag jamage Limit pce Css a cieteocanone a Each Accident $21 Sissies a cietocaoun poceien I Total Premium Per Vehicle $50-76 4-19 $67.04 [Ep Notalipromiuin for FEB 08 2027 toFEB 2820250 hserovabil CONTINUED 03039/01560 See Reverse Side nixon598,(era0 007 (ote025) INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024 This policy is issued by State Farm Indemnity Company. Participating Policy You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in accordance with the Company's Articles of Incorporation, as amended. In Witness Whereof, the State Farm Indemnity Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Herne Yat Chai Schl Secretary President 810 OL] NWSaekAQU ANLT.Ypany PK 19 WV INDM_VOL INDEX NO. 709796/2024 NYSCEF DOCro Néx.2348 DECLARATIONS PAGE ©! VED \YSCEF 05/08/2024 Bloomington IL 61702-2358 PAGE 2 OF 2 POLICY NUMBER a NAMED INSURED 091693 0058 ES INAL, FRANC TSC Isc ‘0 & SOTO POLICY PERIOD FEB 08 2023 to FEB 28 2023 SINDIA 12:01 AM. Standard Time 696 UNION NJ 07083-76 55 STATE FARM PAYMENT PLAN NUMBER 1335705517, as ge 88 os gS be os i i Years in fi ee ess remjer ess than remier 103 Less than re Replaced policy number 1509552-30A. Your total renewal remium for AUG 31 2022 to FEB 28 2023 is $1,459.23, Vehicle 1 $457.25, /ehicle 2 $398.01, Vehicle 3 $603.97. See insert for explanation of class plan 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. Your premium was determined by the information on drivers, driving records, and other information you provided, as well as consumer report information, includin ‘Average number of months since bank revolving accounts established; Total number of claims in the last 60 months; jumber of inquiries for transactions initiated by consumer in the last 6 months. Consumer report reference numbers: 23039171203972, HO8J5PD, 15550891U363690 Credit information was obtained on: SINDIA SOTO 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 coul resullt in a lower rate, no change in rate, or a higher rate. Please refer to the enclosed insert for additional information. Notice of insurance information collection practices - We often collect ersonal information from persons other Such personal in fejo. mation may, in certain circumstances, fibeersonal , family, or household insurance transactions: an the individual or individuals listed on the policy. 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. policy book i ih adda RES BRUM nl ER El 10 ve ake, MENRATRRY ERRORSERNT- LIMITATION ON LAWSUIT OPTION. Agent: MARIA ALAW! Telephone: (862)221-9707 03040/01560 {ora02s4e) Prepared APR 21 2023 095C-B28 rane355-3886-3(o1a025¥d) 08-2007 (ota02Sle) INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024 This policy is issued by State Farm Indemnity Company. Participating Policy You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in accordance with the Company's Articles of Incorporation, as amended. In Witness Whereof, the State Farm Indemnity Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Herne Yat Chai Schl Secretary President 810 INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024 6128CB AMENDATORY ENDORSEMENT This endorsement is a part of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement. 1 DEFINITIONS b. neither available for, nor being used for, carrying persons for a Newly Acquired Car is changed to read: charge. Newly Acquired Car means a car newly b. Exclusions owned by you or a resident relative. (1) Exclusion 5. is changed to read: A car ceases to be a newly acquired car on the earlier of: THERE IS NO COVERAGE FOR AN INSURED FOR DAM- 1 the effective date and time of a pol- AGES ARISING OUT OF THE icy, including any binder, issued by OWNERSHIP, MAINTE- us or any other company that de- NANCE, OR USE OF A VEHI- scribes the car as an insured vehicle; CLE WHILE IT IS: or a. MADE AVAILABLE; OR the end of the 14th calendar day im- mediately following the date the car b. BEING USED is delivered to you or a resident rel- TO CARRY PERSONS FOR A ative. CHARGE. This exclusion does The broadest coverage provided by this not apply to the use of a private policy for any car shown on the Decla- passenger car on a share-the- rations Page under “YOUR CAR” will expense basis; apply to a newly acquired car. (2) The language in exclusion 6. that 2. LIABILITY COVERAGE reads: a. Additional Definition This exclusion does not apply to damage to a: Item 4. of Insured is changed to read: a. motor vehicle owned by the Insured means any other person or employer of you or any res- organization vicariously liable for the ident relative if such dam- use of a vehicle by an insured as de- age is caused by an insured fined in 1., 2., or 3. above, but only while operating another for such vicarious liability. This motor vehicle; provision applies only if the vehicle is: residence while rented to or leased to an insured; or a. neither owned by, nor hired by, that other person or organiza- private garage while rented tion; and to or leased to an insured; Page | of 5 357-6128CB ©, Copyright, State Farm Mutual Automobile Insurance Company, 2015 INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024 is changed to read: is changed to read: This exclusion does not apply to Deductible damage to a: 1 A Comprehensive Coverage de- a. motor vehicle owned by the ductible applies to those vehi- employer of you or the em- cles for which a deductible and a corresponding coverage sym- ployer of any resident rela- bol and premium are shown on tive if such damage is the Declarations Page. caused by an insured while operating another motor ve- A Collision Coverage deducti- hicle; ble applies to those vehicles for which a deductible and a corre- residence while rented to or sponding coverage symbol and leased to an insured; or premium are shown on the Dec- private garage while rented larations Page. to or leased to an insured; Insuring Agreements 3. MEDICAL PAYMENTS COVERAGE Car Rental and Travel Expenses Cov- erage Exclusions Item 4.a. Car Rental Expense is Exclusion 4. is changed to read: changed to read: THERE IS NO COVERAGE FOR AN Car Rental Expense INSURED WHO IS OCCUPYING A VEHICLE WHILE IT IS: We will pay the daily rental charge incurred when an insured rents a car a. MADE AVAILABLE; OR from a car business while your car b. BEING USED or a newly acquired car is: TO CARRY PERSONS FOR A (1) not drivable; or CHARGE. This exclusion does not ap- (2) being repaired ply to: as a result of a loss which would be a. the use of a private passenger car on payable under Comprehensive Cov- a share-the-expense basis; or erage or Collision Coverage. b. an insured while occupying a non- We will pay this daily rental charge owned car as a passenger; incurred during a period that: 4. PHYSICAL DAMAGE COVERAGES (1) starts on the date: a. The paragraph that reads: (a) the vehicle is not drivable as If a deductible applies to Compre- a result of the loss; or hensive Coverage, then it is shown (b) the vehicle is left at a repair on the Declarations Page for the ve- facility if the vehicle is driv- hicles to which it applies. The de- able; and ductible that applies to Collision Coverage is shown on the Declara- (2) ends on the earliest of: tions Page for the vehicles to which (a) the date the vehicle has been it applies. repaired or replaced; Page 2 of 5 357-6128CB ©, Copyright, State Farm Mutual Automobile Insurance Company, 2015 INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024 (b) the date we offer to pay for information we deem neces- the Joss if the vehicle is re- sary to substantiate the pairable but you choose to claim. delay repairs; or Such authorizations must (c) seven days after we offer to not: pay for the Joss if the vehi- (a) restrict us from per- cle is: forming our business (i) a total loss as deter- functions in: mined by us; or (i) obtaining records, (ii) stolen and not recov- bills, information, ered. and data; nor The amount of any such daily rental (ii) using or retaining charge incurred by an insured must records, bills, infor- be reported to us before we will pay mation, and data such amount. collected or re- ceived by us; c. Exclusions (b) require us to violate Exclusion 3. is changed to read: federal or state laws or THERE IS NO COVERAGE FOR regulations; ANY | COVERED VEHICLE (©) prevent us from ful- WHILE IT IS: filling our data report- a. MADE AVAILABLE; OR ing and data retention obligations to insurance b. BEING USED regulators; or TO CARRY PERSONS FOR A (d) prevent us from dis- CHARGE. This exclusion does not closing claim infor- apply to the use of a private passenger mation and data: car on a share-the-expense basis; (i) to enable perfor- 5 INSURED’S DUTIES mance of our busi- ness functions; a. Ttem 6.b.(3) is changed to read: (ii) to meet our report- A person making claim under: ing obligations to b. Medical Payments Coverage, insurance regula- Uninsured and Underinsured tors; Motorist Coverage, or Death, (iii)to meet our report- Dismemberment and Loss of ing obligations to Sight Coverage must: insurance data con- (3) provide written authoriza- solidators; and tion for us to obtain medical (iv)as otherwise per- bills, medical records, wage mitted by law. information, salary infor- mation, employment infor- If an injured insured is a mation, and any other minor, unable to act, or Page 3 of 5 357-6128CB ©, Copyright, State Farm Mutual Automobile Insurance Company, 2015 INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024 dead, then his or her legal any document or notice, including a representative must provide notice to renew, nonrenew, or can- us with the written authori- cel, instead of mailing it or deliver- zation. ing it by other means. Proof of If the holder of the infor- transmission will be sufficient proof mation refuses to provide of notice. it to us despite the authori- Our Rights Regarding Claim In- zation, then at our request formation the person making claim or a We will collect, receive, obtain, his or her legal representative use, and retain all the items de- must obtain the information scribed in item b.(1) below and and promptly provide it to use and retain the information us; and described in item b.(3)(b) be- b. The following is added to item 6.: low, in accordance with applica- A person making claim under Med- ble federal and state laws and ical Payments Coverage, Uninsured regulations and consistent with the performance of our business and Underinsured Motorist Cover- functions. age, or Death, Dismemberment and Loss of Sight Coverage must submit Subject to a. above, we will not to us all information we need to be restricted in or prohibited comply with federal and state laws from: and regulations. (1) collecting, receiving, or ob- 6. GENERAL TERMS taining records, receipts, in- a. The following is added to Newly voices, medical bills, Owned or Newly Leased Car: medical records, wage infor- mation, salary information, Ifa resident relative wants to insure a car newly owned by the resident employment information, relative with the State Farm Com- data, and any other infor- panies after that car ceases to be a mation; newly acquired car, then the resi- (2) sing any of the items de- dent relative must apply to the State scribed in item b.(1) above; Farm Companies for a separate pol- or icy to insure the car newly owned by the resident relative. Such policy (3) retaining: will be issued only if both the appli- (a) any of the items in item cant and the vehicle are eligible for b.(1) above; or coverage at the time of the applica- tion. (b) any other information we have in our posses- b. The following are added to GENERAL sion as a result of our TERMS: processing, handling, Electronic Delivery or otherwise resolving With your consent, we may, if al- claims submitted under lowed by law, electronically deliver this policy. Page 4 of 5 357-6128CB ©, Copyright, State Farm Mutual Automobile Insurance Company, 2015 INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF 05/08/2024 c. We may disclose any of the (4) to meet other obligations re- items in item b.(1) above and quired by law; and any of the information de- (5) as otherwise permitted by law. scribed in item b.(3)(b) above: Our rights under a., b., and c. (1) to enable performance of above shall not be impaired by our business functions; any: (1) authorization related to any (2) to meet our reporting obli- claim submitted under this gations to insurance regula- policy; or tors; (2) act or omission of an in- (3) to meet our reporting obli- sured or a legal representa- gations to insurance data tive acting on an insured’s consolidators; behalf. Page 5 of 5 357-6128CB ©, Copyright, State Farm Mutual Automobile Insurance Company, 2015 : INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024 Neen S® StateFarm: Neen Please read the policy carefully. If there is an accident, contact your State Farm agent or one of our Claim Offices at once. (See “INSURED’S DUTIES’ in this policy booklet.) State Farm® Standard Car Policy Booklet New Jersey Policy Form 9630SA INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024 CONTENTS THIS POLICY... If Other Medical Payments Coverage or DEFINITIONS.... Similar Vehicle Insurance Applies. 24 Our Payment Options........... 25 LIABILITY COVERAGE UNINSURED AND UNDERINSURED Additional Definition MOTORIST COVERAGE.... 25 Insuring Agreement. Additional Definitions 25 Supplementary Payments. Insuring Agreement... 27 Limits... Notice of Tentative Settlement 27 Nonduplicatio Deciding Fault and Amount 28 Exclusions Limits . 28 If Other Liability Coverage Appli Nonduplication . 29 Required Out-of-State Liability Coverag: 10 Exclusions .... 29 Financial Responsibility Certification. 10 If Other Uninsured and Underinsured Motorist Coverage or Other Insurance PERSONAL INJURY PROTECTION Applies 30 COVERAGE... 10 Our Payment Options 31 Section A — Personal Injury Protection PHYSICAL DAMAGE COVERAGES 31 Coverage ..... 10 Additional Definitions. 10 Additional Definitions 31 Exclusions.. 12 Insuring Agreements . 32 Limit of Liabilit 13 Supplementary Payments — Comprehen- sive Coverage and Collision Coverage 34 Policy Perio 14 Limits and Loss Settlement — Compreher Conditions 14 34 sive Coverage and Collision Coverage Section B — Extended Medical Expense Limits — Car Rental and Travel Expenses Benefits Coverage... 17 Coverage. Additional Definitions. 17 Nonduplication 36 Exclusions 18 Exclusions .... 36 Conditions 18 If Other Physical Damage Coverage or Limit of Liability 18 Similar Coverage Applie: Section C — Premium Recomputation 19 Financed Vehicle .... 38 Schedule — Sections A and B. 19 New Jersey Mandatory Inspection Coordination of Benefits... 20 Provision ... 39 Our Payment Options 39 MEDICAL PAYMENTS COVERAGE 21 Additional Definitions............ 21 DEATH, DISMEMBERMENT AND LOSS OF SIGHT COVERAGE... 40 Insuring Agreement........ 22 Determining Medical Expens: 22 Additional Definition 40 Lim 22 Insuring Agreement... 40 Exclusions 23 Benefit . 40 9630SA INDEX NO. 709796/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 05/08/2024 Exclusions...... 41 Where Coverage Applies 44 Our Payment Option 4l Newly Owned or Newly Leased Car. 44 INSURED’S DUTIES 42 Changes to This Policy. 44 Change of Residence. 45 Notice to Us of an Accident or Loss 42 Premium 45 Notice to Us of a Claim or Lawsuit 42 Renewal. 46 Insured’s Duty to Cooperate With Us 42 Nonrenewal 46 Questioning Under Oath... 42 Cancellatio: 46 Other Duties Under the Physical Damage Coverages ..... . 42 Assignment 46 Other Duties Under Medical Payments Bankruptcy or Insolvency of the Insured 47 Coverage, Uninsured and Underinsured Concealment or Fraud 47 Motorist Coverage, and Death, Dismem- Our Right to Recover Our Payments. 47 berment and Loss of Sight Coverage 43 Legal Action Against Us ............ 47 GENERAL TERMS. 44 Choice of Law. 48 When Coverage App! 44 Severability... 48 THIS POLICY This policy consists of: (1) The named insured shown on the a. the most recently issued Declarations Declarations Page is the sole own- Page;