Insurance Policy
Insurance Policy
PO Box 2358
Bloomington IL 61702-2358
HAQUE, REJWAN
A-245C A AUTO RENEWAL
7475 FLYING CLOUD DR APT 454
EDEN PRAIRIE MN 55344-3831 PREMIUM PAID: $657.92
DO NOT PAY.
Your premium is billed through the State Farm Payment Plan
State Farm Payment Plan Number: 1309231205
Various limits are available at your option for coverages: one-time electronic fund transfer from your account or to
A Liability-Bodily Injury/Property Damage P Personal process the payment as a check transaction. When we use
Injury Protection Q Added Income Benefits U Uninsured information from your check to make an electronic fund
Motor Vehicle W Underinsured Motor Vehicle transfer, funds may be withdrawn from your account as soon
as the same day we receive your payment, and you will not
Contact your agent if you are interested in changing your
receive your check back from your financial institution.
limits or adding additional coverages.
When you provide a check as payment, you authorize us
either to use information from your check to make a
TP41
VEHICLE INFORMATION
Review your policy information carefully. If anything is incorrect, or if there are any changes to your vehicle information, please
let us know right away.
Vehicle Identification
Vehicle Description Number (VIN) Who principally drives this vehicle? How is this vehicle normally used?
2021 TOYOTA CAMRY 4T1T11AK0MU551636 REJWAN HAQUE, a married male, who will To Work, School or Pleasure.
be age 35 as of February 08, 2026.
With Drive Safe & Save ®, mileage information and driving model. In addition, we review the comprehensive, collision,
characteristics are used to determine your discount. Your bodily injury and property damage claim experience
calculated annual mileage is 15,800. annually to determine which makes and models have
Premium Adjustment earned decreases or increases from State Farm's standard
Each year, we review our medical payments and personal rates. If any changes result from our reviews, adjustments
injury protection coverages claim experience to determine are reflected in the rates shown on this renewal notice.
the vehicle safety discount that is applied to each make and
DRIVER INFORMATION
Assigned Driver(s)
The following driver(s) are assigned to the vehicle(s) on this policy.
Age as of Marital
Name February 8, 2026 Gender Status
REJWAN HAQUE 35 Male Married
It is your responsibility to inform us of all regular • For business related vehicles, also include the
drivers of your vehicles and changes to those drivers business owner(s) and employee(s) that drive the
throughout the life of your policy. Failure to disclose vehicle(s) in any capacity
drivers may result in denial of coverage. Regular Principal Driver & Assigned Drivers
drivers, regardless of their relationship to the primary For each automobile, the Principal Driver is the individual
named insured or their residence address, include: who most frequently drives it.
• All drivers who drive the vehicle(s) on the policy Each driver is designated as an Assigned Driver on the
once or more in a typical month household automobile that they most frequently drive. Your
• All drivers who regularly drive the vehicle(s) at premium may be influenced by the information shown for
least three months of the year these drivers.
COVERAGE AND LIMITS See your policy for an explanation of these coverages.
A Liability
Bodily Injury 100,000/300,000
Property Damage 100,000 $181.45
P20 Personal Injury Protection
includes Medical 20,000
other expenses to 20,000 $65.84
D 500 Deductible Comprehensive $136.79
G 500 Deductible Collision $192.36
H Emergency Road Service $5.81
R1 Car Rental & Travel Expense
$50 Per Day, $1,500 Max $20.74
U Uninsured Motor Vehicle
Bodily Injury 100,000/300,000 $23.13
W Underinsured Motor Vehicle
Bodily Injury 100,000/300,000 $31.30
$657.42
The claim experience on your make and model of vehicle The claim experience on your make and model of vehicle
has resulted in a reduction to your vehicle rating group for has resulted in a reduction to your liability rating group for
comprehensive coverage. bodily injury and/or property damage coverages.
The claim experience on your make and model of vehicle If any coverage you carry is changed to give broader
has resulted in a reduction to your vehicle rating group for protection with no additional premium charge, we will give
collision coverage. you the broader protection without issuing a new policy,
starting on the date we adopt the broader protection.
Multiple Line P
Antitheft P
Good Driving P
Drive Safe & Save® P
Total Discounts $454.09
ADDITIONAL INFORMATION
If any information on this renewal notice is incomplete or information regarding discounts or coverages, see your
inaccurate, or if you want to confirm the information we have State Farm agent or visit [Link]®.
in our records, please contact your agent. For additional
(10/2022) 153-7414 MN
153-7757 MN
IMPORTANT NOTICE
Regarding Changes to Your Policy
The attached AMENDATORY ENDORSEMENT is added to your State Farm® Car Policy.
It is your responsibility to inform us of all regular drivers of your vehicles and changes to those drivers throughout the life
of your policy. Failure to disclose drivers may result in denial of coverage or other adverse action. Regular drivers,
regardless of their relationship to the primary named insured or their residence address, include:
• All drivers who drive the vehicle(s) on the policy once or more in a typical month
• All drivers who regularly drive the vehicle(s) at least three months of the year
• For business related vehicles, also include the business owner(s) and employee(s) that drive the vehicle(s) in any
capacity
The drivers disclosed to us are listed on the most recent copy of your Auto Renewal. Review the drivers and contact
your Agent if you need to add or remove any listed drivers.
Please read the Amendatory Endorsement and place it with your policy. If you have any questions, please contact your
agent.
DISCLAIMER: This notice only provides a general summary of changes to your State Farm policy. This notice is not a statement of
contract. This notice does not change, modify, or invalidate the provisions, terms, or conditions as set forth in your State Farm policy
booklet, the most recently issued declarations, and any applicable endorsements.
153-7757 MN
(06/2025)
Page 1 of 1
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Page 1 of 5
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. THIS POLICY
a. Item 3. is changed to read:
We agree to provide insurance according to the terms of this policy:
a. based on payment of premium for the coverages carried, the applicable limits, and deducti-
bles chosen;
b. in reliance upon information that affects eligibility and premium provided by you or other
sources to us in the application for this policy and during the policy period. This includes, but
is not limited to:
(1) vehicles insured;
(2) use of your car;
(3) primary garaging location; and
(4) drivers of any vehicle insured under this policy; and
c. unless otherwise stated on the Declarations Page, in reliance on the following statements:
(1) Neither you nor any member of your household has, within the past three years, had
either:
(a) a license to drive; or
(b) a vehicle registration
suspended, revoked, or refused.
(2) Your car is used for pleasure and business.
b. Item 4. is changed to read:
All named insureds shown on the Declarations Page and all applicants agree by acceptance of
this policy that:
a. the statements in 3. above are made by such named insured or applicant and are true;
b. all information provided to us in the application for this policy was true, correct, and complete;
c. all information on the Declarations Page and Auto Renewal is:
(1) true, correct, and complete; and
(2) any changes to information described in 3. above have been provided to us by you if
changed during any policy period; and
d. we provide this insurance on the basis the above statements and information are true, correct,
and complete.
Concealing or misleading material information that affects eligibility or premium may be fraudulent,
resulting in cancellation or nonrenewal of the policy, or denial of coverage under the policy.
2. LIABILITY COVERAGE
Exclusions
Exclusion 14. is changed to read:
THERE IS NO COVERAGE FOR AN INSURED FOR THE OWNERSHIP, MAINTENANCE, OR USE
OF ANY VEHICLE WHILE IT IS:
a. BEING PREPARED FOR, USED IN PRACTICE FOR, OR OPERATED IN ANY PREARRANGED
OR ORGANIZED RACING CONTEST, SPEED CONTEST, HILL-CLIMBING CONTEST, JUMP-
ING CONTEST, OR ANY SIMILAR CONTEST; OR
b. ON A TRACK DESIGNED PRIMARILY FOR RACING OR HIGH-SPEED DRIVING. This exclusion
(14.b.) does not apply if the vehicle is being used in connection with an activity other than racing,
high-speed driving, or any type of competitive driving; OR
3. UNINSURED MOTOR VEHICLE COVERAGE
a. Deciding Fault and Amount
Item 2. is changed to read:
We are not bound by any:
a. judgment or arbitration decision obtained if we have not received timely notice of the com-
mencement of the lawsuit or arbitration; and
b. default judgment or arbitration against any person or organization other than us.
b. Exclusions
The following exclusion is added:
THERE IS NO COVERAGE FOR AN INSURED FOR THE OWNERSHIP, MAINTENANCE, OR
USE OF ANY VEHICLE WHILE IT IS:
a. BEING PREPARED FOR, USED IN PRACTICE FOR, OR OPERATED IN ANY PREAR-
RANGED OR ORGANIZED RACING CONTEST, SPEED CONTEST, HILL-CLIMBING CON-
TEST, JUMPING CONTEST, OR ANY SIMILAR CONTEST; OR
b. ON A TRACK DESIGNED PRIMARILY FOR RACING OR HIGH-SPEED DRIVING. This ex-
clusion (b.) does not apply if the vehicle is being used in connection with an activity other than
racing, high-speed driving, or any type of competitive driving.
4. UNDERINSURED MOTOR VEHICLE COVERAGE
b. Deciding Fault and Amount
Item 2. is changed to read:
We are not bound by any:
b. judgment or arbitration decision obtained if we have not received timely notice of the com-
mencement of the lawsuit or arbitration; and
©, Copyright, State Farm Mutual Automobile Insurance Company, 2025
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Page 3 of 5
b. default judgment or arbitration against any person or organization other than us.
c. Exclusions
(1) Exclusion 1. is changed to read:
THERE IS NO COVERAGE FOR AN INSURED WHO,
WITHOUT PROVIDING US ADVANCE WRITTEN NOTICE AS DESCRIBED UNDER “DECIDING
FAULT AND AMOUNT”, SETTLES WITH ANY PERSON OR ORGANIZATION WHO MAY BE
LIABLE FOR THE BODILY INJURY AND THEREBY PREJUDICES OUR RIGHT TO RECOVER
OUR PAYMENT;
(2) The following exclusion is added:
THERE IS NO COVERAGE FOR AN INSURED FOR THE OWNERSHIP, MAINTENANCE, OR
USE OF ANY VEHICLE WHILE IT IS:
a. BEING PREPARED FOR, USED IN PRACTICE FOR, OR OPERATED IN ANY PREAR-
RANGED OR ORGANIZED RACING CONTEST, SPEED CONTEST, HILL-CLIMBING CON-
TEST, JUMPING CONTEST, OR ANY SIMILAR CONTEST; OR
b. ON A TRACK DESIGNED PRIMARILY FOR RACING OR HIGH-SPEED DRIVING. This ex-
clusion (b.) does not apply if the vehicle is being used in connection with an activity other than
racing, high-speed driving, or any type of competitive driving.
5. PHYSICAL DAMAGE COVERAGE
Exclusions
Exclusion 19. is changed to read:
THERE IS NO COVERAGE FOR ANY COVERED VEHICLE WHILE IT IS:
a. BEING PREPARED FOR, USED IN PRACTICE FOR, OR OPERATED IN ANY PREARRANGED
OR ORGANIZED RACING CONTEST, SPEED CONTEST, HILL-CLIMBING CONTEST, JUMP-
ING CONTEST, OR ANY SIMILAR CONTEST; OR
b. ON A TRACK DESIGNED PRIMARILY FOR RACING OR HIGH-SPEED DRIVING. This exclusion
(19.b.) does not apply if the vehicle is being used in connection with an activity other than racing,
high-speed driving, or any type of competitive driving.
6. DEATH, DISMEMBERMENT AND LOSS OF SIGHT COVERAGE
Exclusions
Exclusion 2.d. is changed to read:
COVERAGE DOES NOT APPLY TO AN INSURED WHILE OCCUPYING, LOADING, OR UNLOAD-
ING A VEHICLE WHILE IT IS:
(1) BEING PREPARED FOR, USED IN PRACTICE FOR, OR OPERATED IN ANY PREARRANGED
OR ORGANIZED RACING CONTEST, SPEED CONTEST, HILL-CLIMBING CONTEST, JUMP-
ING CONTEST, OR ANY SIMILAR CONTEST; OR
(2) ON A TRACK DESIGNED PRIMARILY FOR RACING OR HIGH-SPEED DRIVING. This exclusion
(2.d.(2)) does not apply if the vehicle is being used in connection with an activity other than racing,
high-speed driving, or any type of competitive driving.
7. INSURED’S DUTIES
The following is added:
Duty to Notify Us of Changes
You must notify us if there are changes to any information shown on the Declarations Page or Auto
Renewal, or to information that affects eligibility or premium. This includes, but is not limited to changes
in:
a. use of your car;
b. primary garaging location;
c. drivers of any vehicle insured under this policy; or
d. driver’s license status of any driver.
You must notify us of a newly acquired car within the timing described in the newly acquired car
definition. You must notify us of all other changes within 90 days of that change.
Failure to notify us of changes that affect eligibility or premium may be fraudulent, resulting in cancel-
lation or nonrenewal of the policy, or denial of coverage under the policy.
8. GENERAL TERMS
a. Premium
(1) Item b. is changed to read:
The renewal premium for this policy will be based upon the rates in effect, the coverages
carried, the applicable limits, deductibles, and other elements that affect the premium that
apply at the time of renewal including, but not limited to:
(1) vehicles insured;
(2) use of your car;
(3) primary garaging location; and
(4) drivers of any vehicle insured under this policy.
(2) Item d. is changed to read:
The premium for this policy is based upon the coverages carried, the applicable limits, de-
ductibles, and information we have received from you or other sources. You must inform us
if any information regarding the following is incorrect or incomplete, or changes during the
policy period, and you must answer questions we ask regarding the following:
(1) Your car, or its use, including annual mileage;
(2) The persons who regularly drive your car, including newly licensed family members;
(3) Your marital status; or
(4) The location where your car is primarily garaged.
If the above information or any other information used to determine the premium is incorrect,
incomplete, changes during the policy period, or is not provided to us when we ask, then we
may decrease or increase the premium during the policy period. If we decrease the premium
during the policy period, then we will provide a refund or a credit in the amount of the de-
crease. If we increase the premium during the policy period, then you must pay the amount
of the increase.
b. Cancellation
The following is added to item b.(2):
After this policy has been in force for more than 59 days, we may cancel this policy before the end
of the current policy period for any other reason allowed by law.
c. Concealment or Fraud
The Concealment or Fraud provision is replaced by:
Concealment, Misrepresentation, or Fraud
1. To determine your eligibility for coverage under this policy and to determine your premium,
we relied upon statements and representations you or the applicant provided to us.
2. There is no coverage under this policy and we may cancel or nonrenew this policy, if you or
an applicant have made false statements with the intent to conceal or misrepresent any ma-
terial fact or circumstance in connection with:
a. the application for this policy; or
b. any change to this policy or elements that affect eligibility or premium including, but not
limited to:
(1) vehicles insured;
(2) use of your car;
(3) primary garaging location; and
(4) drivers of any vehicle insured under this policy.
3. There is no coverage under this policy if you or any other person insured under this policy
has made false statements with the intent to conceal or misrepresent any material fact or
circumstance in connection with any claim under this policy.
This provision (3.) does not apply to Liability Coverage.
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