029566751

Consent to Electronic Delivery Please read this notice carefully before giving consent. To complete this insurance transaction on-line, we'll need your consent. Your consent applies to this insurance transaction only. If you consent, the insurance document(s) that you electronically sign can be displayed for you electronically. You will have the opportunity to print or save them and keep them for your records.
To access and retain an electronic record of the insurance document(s), you need a computer with a current version of a web browser, access to the internet, a 56.6K or higher modem, telephone linkage or other internet access device, equipment with the ability to download documents, a current version of Adobe's free Acrobat Reader software and a printer. At any time prior to signing this agreement, you can withdraw your consent by clicking "Cancel" and return to a paper process by calling USAA. If you withdraw your consent, USAA cannot process your application on-line. If you believe that you have made an error in selecting your coverages or wish to make changes, you can decline to electronically sign the insurance document(s) by clicking "Cancel." You agree to print or save this notice and all the electronically signed insurance documents we display for you, and keep copies for your records. If you have any trouble with printing or saving, or would like to request a paper copy, contact USAA. You may send us a request through "Contact Us" on usaa.com. Reasonable fees may be charged for paper copies.

Please print or download a copy of this notice and the insurance document(s) now for future reference. I consent to the use of Electronic Records in connection with my application for insurance. I have been able to read this notice and have successfully printed or downloaded a copy. I acknowledge that I am signing this notice and the insurance document(s) electronically just as if I physically signed a paper document and mailed it to USAA.

Signature of Named Insured

ESIGW(02) Rev. 11-06

60718-1106 Page 1 of 1

029566751

CALIFORNIA UNINSURED MOTORISTS COVERAGES UNINSURED MOTORISTS BODILY INJURY COVERAGE (UMBI)
Below, you will find a brief explanation of Uninsured Motorists Bodily Injury Coverage and Uninsured Motorists Property Damage Coverage. Please remember that this explanation is only an overview, and it does not replace or supplement any of the provisions of your policy. Please see your policy for details because the policy controls all issues of coverage. The decisions you make regarding the amount of coverage will affect your insurance premium. If you have questions, please call Policy Service at 1-800-531-USAA (8722).

Rejection of UMBI Coverage

The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a motor vehicle is operated by a natural person or persons designated by name. Uninsured motorists coverage insures the insured, his or her heirs, or legal representatives for all sums within the limits established by law, that the person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of the same household. Uninsured motorists coverage does not provide any insurance with respect to a vehicle you do not own if the owner of that vehicle has similar insurance.

An uninsured motor vehicle includes an unidentified hit-and-run vehicle or an underinsured motor vehicle defined in subdivision (p) of Section 11580.2 of the Insurance Code as a motor vehicle that is insured for an amount less than your uninsured motorists limits. Underinsured motorists (UIM) coverage pays if you are injured by an at fault motorists whose Bodily Injury (BI) Liability limits are less than your UM coverage limits and less than the amount of damages you are legally entitled to recover from that at-fault motorist. The at-fault motorist's policy pays its BI Liability limits first, then your UM coverage pays the lesser of:

B B

any remaining loss, or the difference between the driver's BI Liability limits and your UM coverage limits.

TO REJECT UMBI COVERAGE, COMPLETE THE REJECTION SECTION ON THE ATTACHED REJECTION/SELECTION FORM. Reduction of UMBI Coverage
The California Insurance Code requires an insurer to provide uninsured motorists coverage in each bodily injury liability insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. Those provisions also permit the insurer and the applicant to agree to provide coverage in an amount less than that required by subdivision (m) of Section 11580.2 of the Insurance Code, but not less than the financial responsibility requirements of $15,000/30,000. Uninsured motorists coverage insures the insured, his or her heirs, or legal representatives for all sums within the limits established by law, that the person or persons are legally entitled to recover as damages for bodily injury, including any resulting sickness, disease, or death, to the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident of the same household. Uninsured motorists coverage does not provide any insurance with respect to a vehicle you do not own if the owner of that vehicle has similar insurance.

999CAW(03) Rev. 2-08

64232-0208 Page 1 of 3

029566751

An uninsured motor vehicle includes an unidentified hit-and-run vehicle, or an underinsured motor vehicle defined in subdivision (p) of Section 11580.2 of the Insurance Code as a motor vehicle that is insured for an amount less than your uninsured motorists limits. Uninsured motorists (UM) coverage pays if you are injured by an at-fault motorist whose BI Liability limits are less than your UM limits and less than the amount of damages you are legally entitled to recover from the at-fault motorist. The at-fault motorist's policy pays its BI Liability limits first, then your UM coverage pays the lesser of:

B B

any remaining loss, or the difference between the driver's BI Liability limits and your UM coverage limits

TO REDUCE UMBI COVERAGE, COMPLETE THE REDUCTION SECTION ON THE ATTACHED REJECTION/SELECTION FORM. Uninsured Motorists Property Damage Coverage (UMPD)

B B

UMPD Coverage is optional and only available when you have purchased UMBI coverage. Pays for damage to your vehicle that you are legally entitled to recover from an at-fault uninsured motorist or hit-and-run vehicle because of property damage sustained in an auto accident. UMPD coverage:

B B

pays the collision deductible on the insured motor vehicle when you have purchased Collision Coverage; or pays for the damage to the insured motor vehicle when you have not purchased Collision Coverage; however, payment shall not exceed the lesser of $3,500, the actual cash value of the insured motor vehicle, or the amount necessary to repair or replace the insured motor vehicle.

You may reject such coverage completely or reject such coverage when any motor vehicle is operated by a natural person or persons designated by name. As used with UMPD coverage, an uninsured motor vehicle does not include an underinsured motor vehicle.

999CAW(03) Rev. 2-08

Page 2 of 3

029566751

REJECTION/SELECTION FORM If you do not wish to make any changes to your current policy, no action is required. TO MAKE CHANGES TO YOUR POLICY, PLEASE COMPLETE THIS FORM AND SIGN IT. The premiums below reflect the total premium for this coverage for all vehicle insured on your Policy. UNINSURED MOTORISTS BODILY INJURY COVERAGE (UMBI) Rejection of UMBI Coverage Limits
X I reject Uninsured Motorists Bodily Injury (UMBI) coverage for this policy and all subsequent

renewals until I request otherwise in writing. I reject UMBI Coverage, and Uninsured Motorists Property Damage (UMPD) Coverage if selected below, for this policy and all subsequent renewals when any motor vehicle is operated by:

Reduction of UMBI Coverage Limits Semi-annual premiums per policy

I want UMBI Coverage in the following limit for this policy and all subsequent renewals which I understand is a limit lower than that required by subdivision (m) of Section 11580.2 of the California Insurance Code: $15,000/30,000 $
22.34

$20,000/40,000 $
35.08

32.17

$25,000/50,000 $ I want UMBI Coverage in the following limits:

(UMBI Coverage limits may not exceed your Bodily Injury Liability Coverage limits.) $ 30,000/ 60,000 $ 50,000/100,000 $100,000/200,000 $100,000/300,000 $ $ $ $
37.98 43.34 52.28 52.95

$ 300,000/ 500,000 $ 500,000/ 500,000 $ 500,000/1,000,000 $1,000,000/1,000,000

$ $ $ $

59.65 63.00 63.90 71.49

UNINSURED MOTORISTS PROPERTY DAMAGE (UMPD) COVERAGE

X I reject UMPD Coverage for this policy and all subsequent renewals until I request otherwise in

writing. You must purchase UMBI Coverage to obtain UMPD Coverage.

DO NOT SIGN UNTIL YOU READ

029566751

USAA Number

Signature of Named Insured

999CAW(03) Rev. 2-08

Page 3 of 3

United Services Automobile Association 9800 Fredericksburg Road - San Antonio, Texas 78288

09/21/2011

BARBARA WELLS ROCK PO BOX 439016 SAN YSIDRO CA 92143-9016

Automobile Insurance Application

Please review, complete and sign where indicated.

OPERATOR INFORMATION Named Insured and Additional Driver(s)

BARBARA ROCK

Date of Birth
09/26/1927

VEHICLE LOCATION and USE Vehicle Detail(s)

Includes Year and Make

Where is the vehicle parked most of the time?

Includes City, State and Zip Code

How do you use this vehicle?*

P/W/S

2010

MERCURY

SAN DIEGO, CA 92101

*Use: P/W/S=Pleasure/Work/School

CAAAPP1W(01) 02-11

94639-0211 Page 1 of 2

Automobile Insurance Application continued, VEHICLE REGISTRATION Vehicle Detail(s)

Includes Year and Make

Registered Owner(s)
BARBARA WELLS ROCK

Vehicle Identification Number (VIN)

2MEBM7FV9AX606679

2010

MERCURY

BY SIGNING BELOW I DECLARE MY BELIEF THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND ACCURATE.
E-signed by

BARBARA ROCK

Signature
For your policy effective on:

09/22/2011

Effective Date

Date
029566751

Policy Number
NONE - DIRECT ISSUE

Agent/Producer

CAAAPP1W(01) 02-11

Page 2 of 2

UNITED SERVICES AUTOMOBILE ASSOCIATION an Interinsurance Exchange San Antonio, Texas Subscriber's Agreement and Limited Power of Attorney
As a United Services Automobile Association (USAA) subscriber, I agree to the following: 1. I appoint the person or entity designated by the USAA Board of Directors as my Attorney-in-Fact to issue insurance policies of USAA under the supervision of the USAA Board of Directors. 2. I understand that USAA is governed by the decisions of a majority of the subscribers voting, in person or by proxy, at any meeting. 3. I shall be bound by the Agreement and the Bylaws of USAA, now and as adopted in the future. 4. I shall not hold any director, officer, employee, or agent of the Attorney-in-Fact or of USAA personally liable for the performance of his, her, or its duties. 5. This Agreement shall be effective whenever I have a policy of insurance in force with USAA and with regard to any rights that arise from being a subscriber of USAA. This Agreement is strictly limited to the use and purpose expressed. Signature: Name:
BARBARA WELLS ROCK

USAA Number: 029566751 Date Signed:

IC389W(01) Rev. 01-11

64472-0111 Page 1 of 1