ATE OF CALIFORN
DEPARTMENT OF MOTOR VEHICLES" NOTIFICATION OF ALTERNATIVE FORMS A Public Service Agency OF FINANCIAL RESPONSIBILITY
California requires that financial responsibility be maintained on any vehicle that is operated or parked on California roadways.
If you received a Notice of Intent to Suspend letter, DMV does not have a record of insurance coverage for the vehicle.
Complete this form to identify the vehicle and return to DMV with a copy of the evidence of coverage.
Mail this completed form with attachments to: DMV - Vehicle Insurance Program (VIP) Unit Mail Station N305
P.O. Box 997408
Sacramento, CA 95899-7408
SECTION 1 — VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER VEHICLE MAKE
1FM5K8GCORGA18769 FORD
LICENSE PLATE NUMBER (IF AVAILABLE) CA NUMBER (IF AVAILABLE) YEAR MODEL 2024 / EXPLORER
SECTION 2 - VEHICLE COVERAGE
My vehicle is covered by one of the following: (Check box and complete section) X COMMERCIAL INSURANCE (A commercial/business liability insurance policy) - Submit a copy of the fleet insurance identification card or a copy of the Declarations Page of your policy with this form.
NAME OF INSURED
City Of Redondo Beach
NAME OF INSURANCE COMPANY NAIC NUMBER
COMMERCIAL POLICY NUMBER POLICY EXPIRATION DATE
• CASH DEPOSIT - Submit a copy of the DMV acknowledgement letter showing the deposit number with this form.
DEPOSIT NUMBER CUSTOMER ID: 5365412; STOCK NUMBER: 240793 R_PCA_REG5085_1110 - 04/23/2024 2:53:
SELF-INSURANCE - Submit a copy of the DMV acknowledgement letter with the assigned self-insured number and the • expiration date with this form.
SELF INSURANCE NUMBER [EXPIRATION DATE
SURETY BOND - Submit a copy of a current surety bond for $35,000 from a company licensed to do business in VANE OF isoria with this form.
NAME OF INSURANCE COMPANY [SURETY BOND NUMBER EXPIRATION DATE SECTION 3 - CERTIFICATION
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
SIGNATURE | DATE
X 05/07/2024
PRINTED NAME OF PERSON SIGNING DAYTIME TELEPHONE NUMBER JAMES A LIGHT FOR : CITY OF REDONDO BEACH (310) 318-0686 R_PCA_REG5085_1110
REG 5085 WWW TREV. 11/2010