DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F

**** SUBMITTED ELECTRONICALLY - DO NOT FAX THIS PAGE TO ANCHOR ****

ENDORSEMENT REQUEST FORM

Policy Number: 3990877 Requested Effective Date: 02/26/2024

User Id: odessa1 Submitted Date: 02/26/2024 2:35 PM
(Pacific Time)
Tracking Number: CA 3153055

Named Insured Producer

96996
MARIN CHIANU ODESSA INS & FIN'L SVCS LLC
5401 GAFIELD AVE APT 58 7433 GREENBACK LN STE H
SACRAMENTO, CA 95841 CITRUS HEIGHTS, CA 95610
(916) 722-1100

You are requesting that the following change be made to your policy:
1) Replace Vehicle

Step 1 of 2: Remove Vehicle Information;

Year: 2004
Make: TOYOTA
Model: RAV4 BASE/
VIN: JTEGD20V840021772
Why being replaced? I SOLD IT

Step 2 of 2: New Vehicle Information;

Year: 2012
Make: TOYOTA
Vehicle Type: PRIVATE PASSENGER
Model: PRIUS V
Usage: PLEASURE
Annual Mileage: 10000
VIN: JTDZN3EU2C3149874
Valid VIN? YES
Body Style: WAG 4D
Performance: STANDARD
Rated Symbols: Liab: N/A Comp: 27 Coll: 29
ISO Symbol: N/A
Four Wheel Drive? NO
8 Cylinder Turbo? NO

Will vehicle be located at current address on file? YES

Additional insured requested? NO

DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F

**** SUBMITTED ELECTRONICALLY - DO NOT FAX THIS PAGE TO ANCHOR ****

ENDORSEMENT REQUEST FORM

Policy Number: 3990877 Requested Effective Date: 02/26/2024

User Id: odessa1 Submitted Date: 02/26/2024 2:35 PM
(Pacific Time)
Tracking Number: CA 3153055

Salvaged? NO
Gray Market? NO
Dually? NO
Van Conversion? NO
Purchase Date: 02/26/2024
Registered Owners: MARIN CHIANU

Any physical damage coverage requested? NO

Any modifications been made to vehicle? NO

Existing Damage? NO

Additional information provided by the Producer

NONE

*** End of requested policy changes ***

Estimated Premium Summary

Current Term Premium:.....$344.00

New Current Term Premium:.....$402.00
Net Term Premium Change:......$58.00 (Additional Premium)

Current Balance:.......$0.00
Net Premium Change:......$46.00
Endorsement Fees:.......$8.40
New Policy Balance:......$54.40

Payment Summary

Endorsement Downpayment:......$15.33
Endorsement Fee:.......$8.40
Total Paid Today:......$23.73

Remaining New Policy Balance :......$30.67

DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F

**** SUBMITTED ELECTRONICALLY - DO NOT FAX THIS PAGE TO ANCHOR ****

ENDORSEMENT REQUEST FORM

Policy Number: 3990877 Requested Effective Date: 02/26/2024

User Id: odessa1 Submitted Date: 02/26/2024 2:35 PM
(Pacific Time)
Tracking Number: CA 3153055

Estimated Payment Schedule*

Installment: Current Due: 04/07/2024 Revised Estimate Due: $25.83

Installment: 1 Due: 05/07/2024 Revised Estimate Due: $10.22
Installment: 2 Due: 06/07/2024 Revised Estimate Due: $10.22

*Future installments do not include installment fees. Current installment may be unchanged.

Endorsement Disclosures

*All changes are subject to underwriting approval.

*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 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 prison.”
*Rates and billing schedules are estimates based on the policy activity and information available
at this time. Rates and schedules are subject to change.
*This transaction includes a $8.40 endorsement fee.

2/26/2024
Applicant's Signature Date

2/26/2024
Producer's Signature Date
DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F

-------------------------------------------- --------------------------------------------

(890003)
CALIFORNIA EVIDENCE OF LIABILITY INSURANCE
DO NOT FOLD OR STAPLE - SUBMIT ORIGINAL TO DMV

This insurance complies with CVC §16056 or §16500.5

SIGNATURE OF INSURANCE REPRESENTATIVE

NAME VEHICLE IDENTIFICATION NUMBER (VIN) MAKE YEAR MODEL

MARIN CHIANU JTDZN3EU2C3149874 TOYOTA 2012

POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE INSURANCE COMPANY NAME

3990877 02-26-2024 07-15-2024 ANCHOR GENERAL INSURANCE COMPANY

INSURANCE COMPANY STREET ADDRESS CITY STATE ZIP CODE NAIC NUMBER

P.O. BOX 509020 SAN DIEGO CA 92150-9020 40010

FR4001002262024071520242012TOY17JTDZN3EU2C314987400000000000000000000083
DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F

INSTRUCTION SHEET
Keep this sheet along with the specified pages in your Producer files.
Policy Number: 3990877 Requested Effective Date: 02/26/2024
User Id: odessa1 Submitted Date: 02/26/2024 2:35 PM
(Pacific Time)
Tracking Number: CA 3153055

Named Insured Producer

MARIN CHIANU 96996
5401 GAFIELD AVE APT 58 ODESSA INS & FIN'L SVCS LLC
SACRAMENTO, CA 95841 7433 GREENBACK LN STE H
CITRUS HEIGHTS, CA 95610
(916) 722-1100

The following information MUST BE RETAINED IN YOUR PRODUCER FILES:

• SIGNED SIGNATURE PAGE(S) FOR ALL EXCLUSIONS, DISCLOSURES AND WAIVERS.
• RETAIN: CURRENT REGISTRATION, TITLE, OR PURCHASE CONTRACT FOR THE: 2012 TOYOTA PRIUS V

****Keep this sheet along with the specified pages in your Producer files****
DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F
*** COMPLETE AND RETAIN THIS PAGE ***

Signature Page Policy Number: 3990877

MARIN CHIANU

ANCHOR GENERAL INSURANCE COMPANY

BUSINESS PURSUITS EXCLUSION ENDORSEMENT
It is understood and agreed that all coverage and any obligation to defend is deleted from the personal automobile policy to which this
endorsement is attached while any motor vehicle covered under this policy is used in any way in the Named Insured’s or any driver’s
business pursuits, occupation, trade, or profession; is used for hire; is used for delivery or pick-up of tangible property including, but not
limited to, food, messages, newspapers, periodicals, packages, or film, for charge, fee, compensation, benefit, or donation whether or not
such charge, fee, compensation, benefit, or donation is actually paid or provided, including the time the motor vehicle is, directly or
indirectly, logged on to any application, platform, or other system used to initiate such activity; or is used in any employment in an
emergency occupation, including, but not limited to, police, fire, and paramedic, on a full-time, part-time, or volunteer basis.

If the Insurance Company listed above is required to make any payments under this policy because of a loss involving a motor vehicle to
which this exclusion applies, the Named Insured must repay us those payments and any expenses.
This exclusion shall be binding upon every insured to whom such policy or endorsement provisions apply while such policy is in force,
and shall continue to be so binding with respect to any continuation, renewal, or replacement of such policy by the named insured, or
with respect to reinstatement of such policy within 30 days of any lapse thereof.

AGIC_CA_BE_2003

By signing and dating below, the insured/applicant acknowledges the Anchor General Insurance Company Business Pursuits Exclusion
Endorsement AGIC_CA_BE_2003

2/26/2024

Insured's/Applicant's Signature Date

DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F

RATING SUMMARY

Policy Number: 3990877 Requested Effective Date: 02/26/2024

User Id: odessa1 Submitted Date: 02/26/2024 2:35 PM
(Pacific Time)
Tracking Number: CA 3153055

Named Insured Producer

96996
MARIN CHIANU ODESSA INS & FIN'L SVCS LLC
5401 GAFIELD AVE APT 58 7433 GREENBACK LN STE H
SACRAMENTO, CA 95841 CITRUS HEIGHTS, CA 95610
(916) 722-1100

Total Policy Premium: $402

Pro Rata Factor: 0.769231
Pro Rated Prior Total: $264
Pro Rated Current Total: $310
Error Message:

Coverage Veh: 1
BI $183
PD $219
MEDPAY $0
PIP $0
UMBI $0
UMPD $0
UIMBI $0
UIMPD $0
CDW $0
CAR LOAN $0
COMP $0
COLL $0
SPEC EQUIP $0
SAFE EQUIP $0

Veh Total $402

DocuSign Envelope ID: 225FBCD2-F494-4A6C-B880-98005DF5665F

*** RETAIN THIS PAGE ***

Payment Receipt

Producer's Copy

Confirmation Number: 5427976

Date Submitted: 2/26/2024 2:35:00 PM (Pacific Time)
Policy Number: 3990877
Insured's Name: MARIN CHIANU
Amount Submitted: $54.40
Producer Information: ODESSA INS & FIN'L SVCS LLC
7433 GREENBACK LN STE H

(916) 722-1100
Insuring Company: ANCHOR GENERAL INSURANCE COMPANY

------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------

Payment Receipt

Insured's Copy

Confirmation Number: 5427976

Date Submitted: 2/26/2024 2:35:00 PM (Pacific Time)
Policy Number: 3990877
Insured's Name: MARIN CHIANU
Amount Submitted: $54.40
Producer Information: ODESSA INS & FIN'L SVCS LLC
7433 GREENBACK LN STE H

(916) 722-1100
Insuring Company: ANCHOR GENERAL INSURANCE COMPANY