<docindex><index>TEIFORM</index></docindex>

Progressive
PO Box 31260
Tampa, FL 33631

Underwritten by:
Progressive Garden State Ins Co

Policy number: 65941813-0

THOMAS JONES Policy period: Jan 5, 2011 - Jul 5, 2011
16 PIERCETOWN RD Effective date: Jan 5, 2011
BRIDGETON, NJ 08302 Expiration date: Jan 25, 2011

800-776-4737
Customer Service - 24 hours a day,
7 days a week

Temporary Evidence of Insurance Coverage

Policyholder: THOMAS JONES

Vehicle Vehicle identification number

………………………………………………………………………………………………………………………………………………………
1996 CHEVROLET C1500/K1500 1GCEC19MXTE125068
………………………………………………………………………………………………………………………………………………………
1998 CHRYSLER CONCORDE 2C3HD46J4WH195284

The Temporary Evidence of Insurance Coverage is not an insurance identification card and should
be destroyed upon receipt of the permanent identification card.
This document cannot be used as proof of insurance for the purpose of having a vehicle
inspected at a Motor Vehicle Commission or private facility.
ADDRESS FOR NOTIFICATION OF COMMENCEMENT OF MEDICAL TREATMENT:

Progressive
c/o Procura
PO Box 879
Oaks, PA 19456
Form Z186 NJ (09/06)