郭文贵破产案 · EXHIBIT · ECF #1805-36

## **Exhibit J**


# **Your New York Automobile Declarations Page**

Your Declarations Page shows at a glance the coverage you have and your premium. Your Declarations Page is part of your policy. Please read your policy carefully, including your Declarations Page and any attached Endorsements, for a description of your coverage.

### **Policy Number: Policy Period:**

**Name of Insured and Mailing Address:**

Hudson Diamond NY LLC 162 E. 64th Street New York, NY,10065

## PCG 0016847665 05/10/2022 - 05/10/2023

At 12:01 A.M. standard time at your mailing address shown

### **Your Broker/Agent Is:**

Wolfson Insurance Brokerage, Inc. 358 Fifth Avenue, 8th Floor New York, NY, 10001

**Name and Address of Issuing Company: AIG Property Casualty Company**

175 Water St, 18th Floor New York, NY 10038

Phone: (212) 683-2622 Broker number: 0051997

# DESCRIPTION OF YOUR COVERED AUTO(S)

| AUTO | YEAR | MAKE | MODEL | VIN | TYPE | GARAGE<br>ZIP | AGREED<br>VALUE | |--------|------|--------------------------|----------|-------------------|------|---------------|-----------------| | 1 | 2019 | ROLLS RO | CULLINAN | SLA689X56KU114001 | REG | 10065 | \$283,712 | | | | DESCRIPTION OF DRIVER(S) | | | | | | | DRIVER | NAME | | | AGE | | | AUTHORIZED | | 1 | | Dean M Rabideau | | 55 | | Covered | | | 2 | | Cao Defeng | | 33 | | Covered | |


# COVERAGE LIMITS, PREMIUMS AND DEDUCTIBLES

| | Premium For… | | | | | | |------------------------------------------------------------|--------------------------------------------------|-------------------------------|----------------------------------------------|------------|--|--| | | | | AUTO 1: | | | | | Type of Coverage | What we will pay | | 2019 | | | | | | | | ROLLS RO | | | | | | | | CULLINAN | | | | | SECTION II – LIABILITY COVERAGES | | | | | | | | Combined Single Limits | \$1,000,000.00 Per Occurrence | | \$698.00 | | | | | | SECTION III – COVERAGE FOR YOUR MEDICAL EXPENSES | | | | | | | Medical Payments | \$50,000.00 Per Person | | \$10.00 | | | | | | SECTION IV – UNINSURED MOTORISTS or SUM COVERAGE | | | | | | | Supplementary<br>UM/UIM*- Single | \$1,000,000.00 Per Occurrence | | \$234.00 | | | | | | SECTION V – COVERAGE FOR DAMAGE TO YOUR AUTO | | | | | | | Collision | Up to the Agreed Value | | \$3,697.00 | | | | | Other than Collision | Up to the Agreed Value | | \$735.00 | | | | | SECTION VI – PERSONAL INJURY PROTECTION | | | | | | | | Basic Personal Injury | \$50,000.00 Per Person | | \$176.00 | | | | | Protection<br>Optional Basic Economic<br>Loss | \$25,000.00 Per Person | | | \$8.00 | | | | Additional Personal Injury<br>Protection | | \$100,000.00 Per Person | | \$25.00 | | | | Aggregate PIP Benefits | | \$175,000.00 Per Person | | \$209.00 | | | | Work Loss | \$4,000.00 Per Month, Max of 3 Years | | | | | | | Other Necessary Expenses<br>\$50.00 Per Day, Max of 1 Year | | | | | | | | Death Benefit | \$2,000.00 Per Person | | | | | | | Additional Death Benefit | \$3,000.00 Per Person | | \$2.00 | | | | | ENDORSEMENTS | | | | | | | | Cash Settlement | Vehicle(s):<br>1 | | \$222.00 | | | | | Motor Vehicle Law<br>Enforcement Fee | | | \$10.00 | | | | | | | Total Annual Premium Per Auto | \$5,817.00 | | | | | | | | Total Annual Premium for All Autos: | \$5,817.00 | | | | Deductibles | | | | | | | | SECTION V – COVERAGE FOR DAMAGE TO YOUR AUTO | | Collision | \$1,000.00 | | | | | | | | (\$0 for Coll<br>Glass Claims) | | | | | | | Other than<br>Collision | \$1,000.00<br>(\$0 for Comp<br>Glass Claims) | | | |

\*The maximum amount payable under SUM coverage shall be the policy's SUM limits, reduced and thus offset by motor vehicle bodily injury liability insurance policy or bond payments received from, or on behalf of, any negligent party involved in the accident, as specified in the SUM endorsement.


# ADDITIONAL COVERAGES PROVIDED

## For Regular and Miscellaneous Vehicles

| COVERAGE | DESCRIPTION | |------------------------------------------------------------|---------------------------------------| | New Vehicle Replacement | Within the first three (3) years | | Transportation Expenses | Up to \$15,000 | | Trip Interruption and Emergency Living Expenses | Up to \$5,000 | | Roadside Assistance | Up to \$100 per day | | Personal Property | Up to \$5,000 | | Pet Injury | Up to \$2,500 | | Vehicle and Home Alteration | Up to \$10,000 | | Vehicle Identity Theft and Fraudulent Title | | | Accidental Airbag Deployment | | | Lock and Key Replacement | | | Towing | Within a 200-mile radius | | Custom Equipment | Up to \$1,500 (Regular Vehicles Only) | | Original Equipment Manufacturer (OEM)<br>Replacement Parts | |

## ADDITIONAL INSURED(S)

**NAME ADDRESS AUTOS**

Hudson Diamond NY, LLC 781 Fifth Ave 18th Floor, New York,NY,10022 Auto 1

## FORMS AND ENDORSEMENTS

| DESCRIPTION | TITLE | |------------------------------------------------------------------------------|--------------------------| | Amendment of Policy Provisions - New York | PCA-AMDPP-NY (01/19) | | Mandatory Personal Injury Protection Coverage Endorsement - New York | PCA-MPIP-NY (01/19) | | Private Client Group Automobile Policy | PCA-PAP (01/19) | | Cash Settlement Option Endorsement | PCA-CSO (01/19) | | Rental Vehicle Coverage Endorsement - New York | PCA-RVC-NY (01/19) | | Additional Personal Injury Protection Coverage Endorsement - New York | PCA-APIP-NY (01/19) | | Uninsured Motorists Endorsement - New York | PCA-UM-NY (01/19) | | Full Coverage Window Glass Endorsement | PCA-FULLGL (01/19) | | Optional Basic Economic Loss Coverage Endorsement - New York | PCA-OBEL-NY (12/19) | | Single Liability Limit Endorsement - New York | PCA-SLL-NY (01/19) | | Federal Employees Using Autos In Government Business Endorsement | PCA-FEDEMP (01/19) | | Change To Insurer's Address - Notice | 141636 (05/21) | | Supplementary Uninsured/Underinsured Motorists Endorsement - New York | PCA-SUPUMUIM-NY (01/19) | | Single Supplementary Uninsured/Underinsured Motorists Endorsement - New York | PCA-SSUPUMUIM-NY (01/19) | | Additional Insured - Lessor Endorsement - New York | PCA-ADIL-NY (01/19) |

## OTHER INFORMATION USED TO RATE YOUR POLICY

| Your | Class Code | Annual Miles | Territory | | Symbols | | | | |--------------|------------|--------------|-----------|------|---------|-----|-----------|--| | Covered Auto | | | | COMP | COLL | LIB | MED / PIP | | | Auto 1 | 945600 | 1629 | 018 | 98 | 98 | N/A | N/A | |

**Tier Designation:** 8


Listed Below are the Premium Discounts and Surcharges that are Applied to Your Policy Premium – New York

Policy Number: PCG 0016847665

Policy Term: 05/10/2022 - 05/10/2023

#### **DISCOUNTS:**

The Premium Discounts listed below are included in your total policy premium:

| DISCOUNT DESCRIPTION | APPLIES TO | | POLICY SAVINGS | |-------------------------------------------|---------------|----------------|----------------| | Five Year Accident Free | Policy | | \$278.00 | | Three Year Safe Driver | Policy | | \$111.00 | | Passive Restraint | Vehicle(s): 1 | | \$87.00 | | Antilock Brake | Vehicle(s): 1 | | \$389.00 | | Anti-theft Device | Vehicle(s): 1 | | \$87.00 | | Supplemental Lines of Business | | | \$742.00 | | Personal excess liability policy discount | Policy | | | | Collections policy discount | Policy | | | | Home insurance policy discount | Policy | | | | | | Total Savings: | \$1,694.00 |

#### **SURCHARGES:**

A Surcharge amount of \$ 0.00 due to accidents/violation and/or inexperienced operator(s) is included in your total policy premium.

Accident Date (s): NONE Violation Date (s): NONE

Your premium reflects a surcharge and is higher because, during the experience period, you had occurrences as outlined above under our rating plan. The Rating Information Disclosure Notice attached describes the rating plan that includes a list of events for which we may surcharge you and the circumstances under which surcharges may be removed. Please contact the Agent or Broker listed on the first page of your Declarations if you have any questions.