Form_SCTNID_CTGRY.

NC09246489_DECPAGE

867426617 E IC78824 INS DECPAGE E POLWHITEFONT OB4WP7SYZLXPUFWCB5CFZM2XEE0001 RPUID TRACWHITEFONT BDF_AA

PROGRESSIVE
P.O. BOX 31260
TAMPA, FL 33631

Policy Number: 867426617

Underwritten by:
Progressive Premier Ins Co of IL
January 12, 2026
BLANC MICHELSON BELIZAIRE SR
Policy Period: Dec 28, 2025 - Jun 28, 2026
433 STARLIT DR
FAYETTEVILLE, NC 28312 Page 1 of 2

[Link]
Online Service
Make payments, check billing activity, update
policy information or check status of a claim.

Auto Insurance 1-800-776-4737

Coverage Summary
For customer service and claims service,
24 hours a day, 7 days a week.

This is your Declarations Page

Your policy information has changed
Your coverage began on December 28, 2025 at the later of 12:01 a.m. or the effective time shown on your application. This policy
period ends on June 28, 2026 at 12:01 a.m.
This coverage summary replaces your prior one. Your insurance policy and any policy endorsements contain a full explanation of your
coverage. The policy limits shown for a vehicle may not be combined with the limits for the same coverage on another vehicle. The
policy contract is form NC0001 (06/05). The contract is modified by forms NC0301 (07/87), NC0350 (09/04), NC0012 (10/23) and
NC0013 (07/25).

Policy changes effective December 28, 2025

………………………………………………………………………………………………………………………………………………………..
Changes requested on: Dec 28, 2025
………………………………………………………………………………………………………………………………………………………..
Requested by: Progressive
………………………………………………………………………………………………………………………………………………………..
Premium change: -$1,616.13
………………………………………………………………………………………………………………………………………………………..
Changes: Policy cession status changed

Underwriting Company
Progressive Premier Ins Co of IL
P.O. Box 31260
Tampa , FL 33631
1-800-776-4737

Drivers and household residents

Blanc michelson Belizaire SR
Additional information: Named insured

Outline of coverage
General policy coverage Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Combined Uninsured/Underinsured Motorist $50,000 each person/$100,000 each accident $32
………………………………………………………………………………………………………………………………………………………..
Uninsured Motorist Property Damage $50,000 each accident $100 2
………………………………………………………………………………………………………………………………………………………..
Total premium for general policy coverage $34.00

Form 6489 NC (09/24)

4
Continued
867426617 E IC78824 INS DECPAGE E POLWHITEFONT OB4WP7SYZLXPUFWCB5CFZM2XEE0001 RPUID TRACWHITEFONT BDF_AA

Policy Number: 867426617

Blanc michelson Belizaire SR
Page 2 of 2
2015 CHRYSLER 200 4 DOOR SEDAN
VIN: 1C3CCCAB1FN718789
Garaging Zip Code: 28312
Primary use of the vehicle: 10+Miles
Annual miles: 18,000 - 19,999
Length of vehicle ownership when policy started or vehicle added: At least 6 months but less than 1 year
Limits Deductible Premium
………………………………………………………………………………………………………………………………………………………..
Liability Coverage $375
Bodily Injury Liability $50,000 each person/$100,000 each accident
Property Damage Liability $50,000 each accident
………………………………………………………………………………………………………………………………………………………..
Total premium for 2015 CHRYSLER $375
………………………………………………………………………………………………………………………………………………………..
Subtotal policy premium $409.43
………………………………………………………………………………………………………………………………………………………..
Policy fee 15.00
………………………………………………………………………………………………………………………………………………………..
Total 6 month policy premium and fees $424.43

Premium discounts
Policy
………………………………………………………………………………………………………………………………………………………..
867426617 Automatic Card Payments (ACP), Online Signature - First Policy Period Only,
Online Quote and Paperless
Vehicle
………………………………………………………………………………………………………………………………………………………..
2015 CHRYSLER Airbag and Snapshot Participation
200

Form 6489 NC (09/24)