Driver Service
Resume:
Named Insured(s)
WILLINGHAM, EDWARD M
DES MOINES IA 50320-1124
LIGOURI AND ASSOCIATES INC
VIKING INSURANCE COMPANY OF WISCONSIN
P O BOX 35396
DES MOINES IA 50315-0304 Phone: 1-515-***-****
Agency Code: 28951
DAADDTFAATDATFADTDFTADFFDDDDTDTATADFFTDFDTFDTTFADFTTDAFTFFFAFTAAA My.DairylandInsurance.com
DECLARATIONS PAGE
Policy Number
Policy Term
Transaction
Effective
08/01/2022 to 08/01/2023
Transaction Policy Change
Type
08/01/2022
Email: ****************@*****.***
This Is Not a Bill. Retain for your records.
Nothing contained in these documents changes the cancellation, expiration or nonrenewal date listed on any outstanding bill, offer or notice sent to you.
Change Description
Premium and Coverage Information
Vehicle Level Coverages Limits Vehicle 1
Rated Driver 1
Bodily Injury Liability $20,000 Each Person/$40,000 Each accident $355.45 Property Damage Liability $15,000 Each accident $553.39 Medical Payments $1,000 Each Person $14.00
Roadside Assistance $100, Per Service; 3 Max Services $96.00 Subtotal Premium By Vehicle $1,018.84
Policy Level Coverages Limits Deductible Premium
Uninsured Motorist Bodily Injury $20,000 Each Person/$40,000 Each accident $17.23 Underinsured Motorist Bodily Injury $20,000 Each Person/$40,000 Each accident $17.33 Subtotal Premium By Policy $34.56
Premium Summary
Premium Subtotal $1,053.40
Policy Fee $10.00
Total Policy Premium $1,063.40
Vehicle Information
Veh # Year Make Model VIN Existing Damage Vehicle Location 1 1999 Cadillac DEVILLE D'ELEGANCE 1G6KE54Y9XU756021 N 50320 DECA-0316 Process Date: 08/01/2022 - 09:47 AM Central Time per Stevens Point, WI Page 1 of 2 0027020044366217157450320112409
DECA-0316 Process Date: 08/01/2022 - 09:47 AM Central Time per Stevens Point, WI Page 2 of 2 0027020044366217157450320112409
Driver Information
Drv # Name Date of Birth Gender Marital Financial Responsibility Status
1 WILLINGHAM, EDWARD M 02/12/1966 M S
Accident and Violation Information
Drv # Date of Occurrence Type Points Description of Occurrence 1 01/27/2021 Violation 2 Speed
Policy Forms
The following policy forms and endorsements apply to your policy. IAA1101-1021 MPHN1-0121 PAP1-1213
PPA-IA-0420 RAA-0915 UIMA-IA-0816
UMA1-IA-0415
Important Messages
Access your policy documents online at My.DairylandInsurance.com. Important: This form shows changes you have made to your insurance policy. To continue your insurance you must pay any outstanding bill or offer sent to you before the due date or cancellation/expiration date of that notice. This policy is effective on the date shown on the face of these declarations. These declarations form a part of the policy and replace all previously issued declarations for this policy. If these declarations are accompanied by a new policy, this policy replaces any which may have been issued previously with the same policy number.
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