NEW AUTOMOBILE POLICY DECLARATIONS

Old American Indemnity Company

NAIC: 11665
ADMINISTERED BY: BLUEFIRE INSURANCE SERVICES
P.O. BOX 143249; Irving, TX 75014-3249
LA License #498351
THIS DECLARATION PAGE IS PART OF YOUR POLICY. PLEASE READ IT CAREFULLY.

NAMED INSURED: PRODUCER: 7405

Phone Number: (800)958-8545

MATTHEW LAMBERT USAGENCIES

1907 NESOM RD 440 N. THIRD ST #8TH FL
DENHAM SPRINGS, LA 70706-0000 BATON ROUGE, LA 70802-0000

POLICY NUMBER: OLA0195171 POLICY TERM: 09/14/2023 to 03/14/2024 at 12:01 A.M. Garaging Zip: 70706

COVERAGES AND PREMIUMS – Coverage is provided only if a premium is shown for the indicated coverage.
COVERAGES LIMITS OF LIABILITY VEH 1 VEH VEH VEH VEH

PER PER
BODILY INJURY LIABILITY $15,000 $30,000 $780
PERSON ACCIDENT
PROPERTY DAMAGE
$25,000 PER ACCIDENT $454
LIABILITY
MEDICAL PAYMENTS PER PERSON, PER ACCIDENT
PER PER
UM BODILY INJURY
PERSON ACCIDENT
UM PROPERTY DAMAGE PER ACCIDENT ($250 Ded. Applies)
OTHER THAN COLLISION 1
COLLISION 1

RENTAL REIMBURSEMENT

PER VEHICLE TOTALS $1,234

FORMS AND ENDORSEMENTS WHICH APPLY: TOTAL COVERAGE PREMIUM $1,234.00
LA OAIC BUSEXCL 08 20, LA OAIC APP 08 20, LA OAIC PAP 08 20, LA OAIC UM
COV 08 20, LA OAIC PRIVACY 12 18, LA OAIC NDEXCL 08 20 POLICY FEE $60.00
SR22 FILING FEE(S) $0.00
MVR FEE $10.00
TOTAL PREMIUM AND FEES $1,304.00

VEHICLE DESCRIPTION – Coverage is provided only for the vehicles listed below and only if at the listed garaging address.
Discounts/ Vehicle Rated
# YR MAKE MODEL VIN Symbols
Surcharges Use Driver
1 2009 SUBARU FORESTER 2.5X JF2SH61629H703767 14/ 14 DRL Pleasure 1

Vehicle or Policy Level Discount Codes: MC=Multi-Car Discount / TR=Transfer Discount / VE=VIN Etching Discount / RD=Renewal
Discount / AT=In-Agency Transfer / / DRL=Daytime Running Lights / GPS=GPS Discount /
Vehicle or Policy Level Surcharge Codes: BU=Business Use Surcharge

LA OAIC DEC 08 20 Page 1 of 2 Date Printed: 09/14/2023

Insured Copy
 Policy Number: OLA0195171

LIENHOLDERS /ADDITIONAL INSUREDS

# Type Name Address

COVERED DRIVER(S) - Coverage is provided for the drivers listed below.

Years Marital Discounts/
# Name DOB License # St Gender Points* Class
Licensed Status Surcharges
1 MATTHEW 09/20/1992 14 012833444 LA Male Single 4 SM30
LAMBERT

Driver Discount Codes: MI=Military Discount / DD=Defensive Driver Discount / DD55=55 and Older Defensive Driver Discount
Driver Surcharge Codes: UMVR=Unverifiable MVR / FDL=Foreign License Surcharge / INA=Inactive License Surcharge

*Note: The detailed information regarding traffic violations and accidents that are being considered in developing the premium for this policy,
if applicable, are available to you upon request.

EXCLUDED DRIVER(S): This policy shall not apply nor accrue to the benefit of any insured or any third party when any
vehicle is being used or driven by a person listed below.

THIS REPLACES ALL PREVIOUSLY ISSUED POLICY DECLARATIONS, IF ANY. THIS POLICY APPLIES
ONLY TO ACCIDENTS, OCCURRENCES, OR LOSSES WHICH HAPPEN DURING THE POLICY PERIOD
SHOWN ABOVE.

LA OAIC DEC 08 20 Page 2 of 2 Date Printed: 09/14/2023

Insured Copy
THE ATTACHED IDENTIFICATION CARD(S) MUST BE CARRIED IN THE INSURED MOTOR VEHICLE(S) AT ALL
TIMES AND PRESENTED UPON DEMAND
R.S. 32:863.1 requires that an operator of a motor vehicle produce
Old American Indemnity Company upon demand by a law enforcement officer documentation of motor
PO Box 143249, Irving, TX 75014-3249; Lic #498351
vehicle security which is required to be maintained within the vehicle
To Report a Claim Please Call: 1-800-877-0226
at all times. Failure to comply may result in fines, revocation of
LOUISIANA MOTOR VEHICLE INSURANCE IDENTIFICATION CARD registration privileges and block against the renewal or issuance of a
driver's license.
NAIC Code: 11665
Policy Number Effective Date Expiration Date Excluded Drivers: NONE
OLA0195171 09/14/2023 03/14/2024

Policyholder(s)
MATTHEW LAMBERT IN CASE OF ACCIDENT
1907 NESOM RD Report all accidents to your Producer/Company as soon as possible. Obtain the
DENHAM SPRINGS, LA 70706-0000 following information:

Insured Vehicle VIN 1. Name and address of each driver, passenger and witness.
2009 SUBARU FORESTER 2.5X JF2SH61629H703767 2. Name of Insurance Company and policy number for each vehicle
involved.
An insurer authorized to transact business in Louisiana has issued 3. YOUR POLICY IS CONFIDENTIAL – Do not show it to anyone
the Motor Vehicle Policy identified hereon. The coverage provided by
this policy meets the minimum liability limits prescribed by law. THIS
except an authorized representative of this company.
CARD MUST BE CARRIED IN THE VEHICLE AT ALL TIMES AS Make no statements of any kind or admit fault before or after making the report
EVIDENCE OF LIABILITY INSURANCE. regarding the accident to anyone except the proper police authorities or a
representative of the company.

R.S. 32:863.1 requires that an operator of a motor vehicle produce

Old American Indemnity Company upon demand by a law enforcement officer documentation of motor
PO Box 143249, Irving, TX 75014-3249; Lic #498351
vehicle security which is required to be maintained within the vehicle
To Report a Claim Please Call: 1-800-877-0226
at all times. Failure to comply may result in fines, revocation of
LOUISIANA MOTOR VEHICLE INSURANCE IDENTIFICATION CARD registration privileges and block against the renewal or issuance of a
driver's license.
NAIC Code: 11665
Policy Number Effective Date Expiration Date Excluded Drivers: NONE
OLA0195171 09/14/2023 03/14/2024

Policyholder(s)
MATTHEW LAMBERT IN CASE OF ACCIDENT

VOID
1907 NESOM RD Report all accidents to your Producer/Company as soon as possible. Obtain the
DENHAM SPRINGS, LA 70706-0000 following information:

Insured Vehicle VIN 1. Name and address of each driver, passenger and witness.
2. Name of Insurance Company and policy number for each vehicle
involved.
3. YOUR POLICY IS CONFIDENTIAL – Do not show it to anyone
An insurer authorized to transact business in Louisiana has issued
the Motor Vehicle Policy identified hereon. The coverage provided by
except an authorized representative of this company.
this policy meets the minimum liability limits prescribed by law. THIS Make no statements of any kind or admit fault before or after making the
CARD MUST BE CARRIED IN THE VEHICLE AT ALL TIMES AS report regarding the accident to anyone except the proper police authorities or
EVIDENCE OF LIABILITY INSURANCE. a representative of the company.

R.S. 32:863.1 requires that an operator of a motor vehicle produce

Old American Indemnity Company upon demand by a law enforcement officer documentation of motor
PO Box 143249, Irving, TX 75014-3249; Lic #498351
vehicle security which is required to be maintained within the vehicle
To Report a Claim Please Call: 1-800-877-0226
at all times. Failure to comply may result in fines, revocation of
LOUISIANA MOTOR VEHICLE INSURANCE IDENTIFICATION CARD registration privileges and block against the renewal or issuance of a
driver's license.
NAIC Code: 11665
Policy Number Effective Date Expiration Date Excluded Drivers: NONE
OLA0195171 09/14/2023 03/14/2024

Policyholder(s)
IN CASE OF ACCIDENT
MATTHEW LAMBERT

VOID
1907 NESOM RD Report all accidents to your Producer/Company as soon as possible. Obtain the
DENHAM SPRINGS, LA 70706-0000 following information:

Insured Vehicle VIN 1. Name and address of each driver, passenger and witness.
2. Name of Insurance Company and policy number for each vehicle
involved.
An insurer authorized to transact business in Louisiana has issued 3. YOUR POLICY IS CONFIDENTIAL – Do not show it to anyone
the Motor Vehicle Policy identified hereon. The coverage provided by except an authorized representative of this company.
this policy meets the minimum liability limits prescribed by law. THIS Make no statements of any kind or admit fault before or after making the report
CARD MUST BE CARRIED IN THE VEHICLE AT ALL TIMES AS regarding the accident to anyone except the proper police authorities or a
EVIDENCE OF LIABILITY INSURANCE. representative of the company.

LA- IDCARDS (12/18)