4/24/24, 7:16 AM Auto Forms
KANSAS INSURANCE CARD THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
FIRST CHICAGO INSURANCE COMPANY
PO BOX 389508 CHICAGO, IL 60638-9508 (888) 262-8864 IN CASE OF ACCIDENT
Company: Producer: 1. File a report with the police.
FIRST CHICAGO INSURANCE COMPANY SEGUROS SIN BARRERAS INS
PO BOX 389508 SRVS 2. Express no opinion relative to responsibility
CHICAGO, IL 60638-9508 (888) 672-6999 and/or liability for the accident.
NAIC# 13587 PRODUCER CODE: 3523433 3. Exchange insurance information with other
driver(s) involved.
NAME OF INSURED:
LEYDERS Rivas JOSE ECHEVERRIA 4. It is imperative to obtain the names, addresses
and telephone numbers of any and all
witnesses.
POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE
KSB 940635-00 02/06/2024 08/06/2024 5. Protect the vehicle from the possibility of
incurring further damage if unable to drive from
the scene.
VEHICLE DESCRIPTION
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER 6. Report accidents involving property damage
and/or personal injury to our representative
2011 KIA / RIO BASE/RIO KNADH4A30B6936322
(888) 262-8864
LX/RIO SX
7. Submit a completed written accident/loss report
EXAMINE POLICY EXCLUSIONS CAREFULLY. THIS FORM DOES NOT
(enclosed with your policy) within 72 hours of
Leyders Rivas eSign: 4/24/2024 9:18 AM CDT, IP: [Link]
CONSTITUTE ANY PART OF YOUR INSURANCE POLICY.
the accident date.
BIC KS 109 (1/11)
[Link] 1/3
4/24/24, 7:16 AM Auto Forms
KANSAS INSURANCE CARD THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
FIRST CHICAGO INSURANCE COMPANY
PO BOX 389508 CHICAGO, IL 60638-9508 (888) 262-8864 IN CASE OF ACCIDENT
Company: Producer: 1. File a report with the police.
FIRST CHICAGO INSURANCE COMPANY SEGUROS SIN BARRERAS INS
PO BOX 389508 SRVS 2. Express no opinion relative to responsibility
CHICAGO, IL 60638-9508 (888) 672-6999 and/or liability for the accident.
NAIC# 13587 PRODUCER CODE: 3523433 3. Exchange insurance information with other
driver(s) involved.
NAME OF INSURED:
LEYDERS Rivas JOSE ECHEVERRIA 4. It is imperative to obtain the names, addresses
and telephone numbers of any and all
witnesses.
POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE
KSB 940635-00 02/06/2024 08/06/2024 5. Protect the vehicle from the possibility of
incurring further damage if unable to drive from
the scene.
VEHICLE DESCRIPTION
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER 6. Report accidents involving property damage
and/or personal injury to our representative
2023 KIA / RIO LX/S 3KPA24AD7PE512671
(888) 262-8864
EXAMINE POLICY EXCLUSIONS CAREFULLY. THIS FORM DOES NOT
CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. 7. Submit a completed written accident/loss report
(enclosed with your policy) within 72 hours of
Leyders Rivas eSign: 4/24/2024 9:18 AM CDT, IP: [Link]
the accident date.
BIC KS 109 (1/11)
[Link] 2/3
4/24/24, 7:16 AM Auto Forms
KANSAS INSURANCE CARD THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
FIRST CHICAGO INSURANCE COMPANY
PO BOX 389508 CHICAGO, IL 60638-9508 (888) 262-8864 IN CASE OF ACCIDENT
Company: Producer: 1. File a report with the police.
FIRST CHICAGO INSURANCE COMPANY SEGUROS SIN BARRERAS INS
PO BOX 389508 SRVS 2. Express no opinion relative to responsibility
CHICAGO, IL 60638-9508 (888) 672-6999 and/or liability for the accident.
NAIC# 13587 PRODUCER CODE: 3523433 3. Exchange insurance information with other
driver(s) involved.
NAME OF INSURED:
LEYDERS Rivas JOSE ECHEVERRIA 4. It is imperative to obtain the names, addresses
and telephone numbers of any and all
witnesses.
POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE
KSB 940635-00 02/06/2024 08/06/2024 5. Protect the vehicle from the possibility of
incurring further damage if unable to drive from
the scene.
VEHICLE DESCRIPTION
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER 6. Report accidents involving property damage
and/or personal injury to our representative
2013 HYUNDAI / ELANTRA KMHDH4AE1DU896900
(888) 262-8864
GLS/ELANTRA
LIMITED 7. Submit a completed written accident/loss report
(enclosed with your policy) within 72 hours of
Leyders Rivas eSign: 4/24/2024 9:18 AM CDT, IP: [Link]
EXAMINE POLICY EXCLUSIONS CAREFULLY. THIS FORM DOES NOT
CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. the accident date.
BIC KS 109 (1/11)
[Link] 3/3