郭文贵破产案 · EXHIBIT · ECF #2032-30

# **Exhibit 30**


# **Policy Notice**

# **(See Your Revised 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:** Golden Spring (New York) Ltd. 162 E 64th St New York, NY 10065

At 12:01 A.M. standard time at your mailing address shown 04/01/2022 - 04/01/2023

**Your Broker/Agent Is:**

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

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

### **Name of Issuing Company:**

AIG Property Casualty Company

# **Your Policy Has Been Changed**

**Effective Date:** 04/01/2022

**Description of Change:** Delete 2017 Lexus LX 570 #9861

**Revised Annual Premium: Premium Charge for Endorsement:** \$19,391.00

**From: To:** -\$3,628.00 04/01/2022 04/01/2023

**This summary of coverage provides you with complete policy information, including the above change, and represents your coverage currently in effect.**


| AUTO AUTO | YEAR | | MODEL | vin | TYPE | GARAGE<br>ZIP | AGREED<br>VALUE | |-----------|------|------------------------|-------|-----------------------|------|---------------|-----------------| | | | 2018 MERCEDES S650x | | WDDUX8AB4JA400527 REG | | 10022 | \$144.878 | | 2 | 2020 | MERCEDES Airstream | | WDAFF4CD5KT014771 MOT | | 10065 | \$133.867 | | ന | | 2021 | | 4JGFF8HB0MA399467 REG | | 10022 | \$142.158 |

| DRIVER | NAME | AGE | AUTHORIZED | |--------|----------------------|-----|------------| | | Cao Defeng | 33 | Covered | | 2 | Gerald Scott Barnett | 50 | Covered |



# COVERAGE LIMITS, PREMIUMS AND DEDUCTIBLES

| | COVERAGE LIMITS, PREMIUMS AND DEDUCTIBLES | | | | | | | |---------------------------------------------------|--------------------------------------------------|-------------------------------|--|----------------------------------------------|----------------------------------------------|----------------------------------------------|--| | | | | | Premium For… | | | | | | What we will pay | | | AUTO 1: | AUTO 2: | AUTO 3: | | | Type of Coverage | | | | 2018<br>MERCEDES<br>S650x | 2019<br>MERCEDES<br>Airstream | 2021<br>MERCEDES<br>GLS | | | SECTION II – LIABILITY COVERAGES | | | | | | | | | Combined Single Limits | \$1,000,000.00 Per Occurrence | | | \$911.00 | \$609.00 | \$1,336.00 | | | | SECTION III – COVERAGE FOR YOUR MEDICAL EXPENSES | | | | | | | | Medical Payments | \$50,000.00 Per Person | | | \$8.00 | \$4.00 | \$9.00 | | | | SECTION IV – UNINSURED MOTORISTS or SUM COVERAGE | | | | | | | | Supplementary<br>UM/UIM*- Single | \$1,000,000.00 Per Occurrence | | | \$289.00<br>\$145.00<br>\$289.00 | | | | | | SECTION V – COVERAGE FOR DAMAGE TO YOUR AUTO | | | | | | | | Collision | Up to the Agreed Value | | | \$3,880.00 | \$3,067.00 | \$4,362.00 | | | Other than Collision | Up to the Agreed Value | | | \$1,184.00 | \$770.00 | \$1,251.00 | | | | SECTION VI – PERSONAL INJURY PROTECTION | | | | | | | | Basic Personal Injury | \$50,000.00 Per Person | | | \$226.00 | \$144.00 | \$243.00 | | | Protection<br>Optional Basic Economic<br>Loss | \$25,000.00 Per Person | | | \$7.00 | \$7.00 | \$7.00 | | | Additional Personal Injury<br>Protection | \$100,000.00 Per Person | | | \$21.00 | \$21.00 | \$21.00 | | | Aggregate PIP Benefits | \$175,000.00 Per Person | | | \$254.00 | \$172.00 | \$271.00 | | | Work Loss | \$4,000.00 Per Month, Max of 3 Years | | | | | | | | Other Necessary Expenses | \$50.00 Per Day, Max of 1 Year | | | | | | | | Death Benefit | \$2,000.00 Per Person | | | | | | | | Additional Death Benefit<br>\$3,000.00 Per Person | | | | \$2.00 | | \$2.00 | | | ENDORSEMENTS | | | | | | | | | Accidental Death Benefit | \$15,000.00 Per Policy | | | \$12.00 | Included | Included | | | Cash Settlement | Vehicle(s):<br>1<br>3 | | | \$253.00 | | \$281.00 | | | Motor Vehicle Law<br>Enforcement Fee | | | | \$10.00 | \$10.00 | \$10.00 | | | | | Total Annual Premium Per Auto | | \$6,803.00 | \$4,777.00 | \$7,811.00 | | | | | | | | Total Annual Premium for All Autos: | \$19,391.00 | | | Deductibles | | | | | | | | | | SECTION V – COVERAGE FOR DAMAGE TO YOUR AUTO | Collision | | \$1,000.00<br>(\$0 for Coll<br>Glass Claims) | \$1,000.00<br>(\$0 for Coll<br>Glass Claims) | \$1,000.00<br>(\$0 for Coll<br>Glass Claims) | | | | | Other than<br>Collision | | \$1,000.00<br>(\$0 for Comp<br>Glass Claims) | \$1,000.00<br>(\$0 for Comp<br>Glass Claims) | \$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 | |

# FORMS AND ENDORSEMENTS

| DESCRIPTION | TITLE | |------------------------------------------------------------------------------|--------------------------| | Private Client Group Automobile Policy | PCA-PAP (01/19) | | Amendment of Policy Provisions - New York | PCA-AMDPP-NY (01/19) | | Mandatory Personal Injury Protection Coverage Endorsement - New York | PCA-MPIP-NY (01/19) | | Auto Accidental Death Benefit Endorsement | PCA-ACCD (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) | | 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) | | Cash Settlement Option Endorsement | PCA-CSO (01/19) | | Federal Employees Using Autos In Government Business Endorsement | PCA-FEDEMP (01/19) | | 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) | | Miscellaneous Type Vehicle Endorsement | PCA-MISCVEH (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 | P33C1000N | 3512 | 018 | 98 | 98 | N/A | N/A | | Auto 2 | 943700 | 9500 | 018 | | | N/A | N/A | | Auto 3 | P50F1000N | 9500 | 018 | 98 | 98 | N/A | N/A |

**Tier Designation:** 4


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

Policy Number:

Policy Term: 04/01/2022 - 04/01/2023

### **DISCOUNTS:**

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

| DISCOUNT DESCRIPTION | APPLIES TO | | POLICY SAVINGS | |-----------------------|-------------------|----------------|----------------| | Daytime Lights | Vehicle(s): 1,3 | | \$345.00 | | Antilock Brake | Vehicle(s): 1,3 | | \$345.00 | | Automatic Braking | Vehicle(s): 1 | | \$105.00 | | Blind Spot Monitoring | Vehicle(s): 1 | | \$105.00 | | Passive Restraint | Vehicle(s): 1,3 | | \$144.00 | | Anti-theft Device | Vehicle(s): 1,2,3 | | \$283.00 | | | | Total Savings: | \$1,327.00 |

### **SURCHARGES:**

A Surcharge amount of \$ 1,497.00 due to accidents/violation and/or inexperienced operator(s) is included in your total policy premium.

Accident Date (s): 01/13/2021

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.


## **Notice of Information Practices**

State law requires us to notify you of our information gathering practices and your rights relating to those practices.

While we rely heavily on the information applicants and insureds supply to us, we may also collect personal information from other sources.

For instance, as part of our normal underwriting procedure, we will review motor vehicle records obtained from the Department of Motor Vehicles on all operators in your household and, we will review the claims history that you have had with any prior insurance company or companies, which we will obtain from a nationally recognized consumer investigative firm.

We will not disclose any personal information which we have collected or received in connection with any insurance transaction unless you (or any other affected person) approves that disclosure except as permitted by law in the following circumstances:

- 1. to persons or organizations, where necessary, to allow performance of a business, professional or insurance function for us; or, to allow the person or organization to assist us in determining your eligibility for insurance or in detecting insurance fraud; - 2. to other insurers, agents or insurance support organizations, where necessary, to complete an insurance transaction or to help detect fraud or other illegal activities; - 3. to a medical care institution or medical professional to verify insurance coverage or benefits or to alert an individual to a medical problem, or to conduct a service audit; - 4. to an insurance regulatory authority; - 5. to a law enforcement or other governmental authority, where necessary, to protect insurer interests or to assist in the investigation of fraud or other criminal activities; - 6. to facilitate actuarial or research studies; - 7. to permit marketing of selected products or services to insureds, although you have the right to tell us that you do not wish to have personal information released for marketing purposes; - 8. to any of our affiliated companies whose use of personal information will be for auditing or marketing purposes; - 9. (where relevant) to a group policyholder for the purpose of reporting claims experience or conducting an audit of insurance transactions.

You can obtain access to any personal information we have about you if you properly identify yourself and submit a written request to us describing the information you want to review. Once we have received your request, and if the information is reasonably locatable and retrievable, we will, within 30 business days, take the following actions:

- 1. inform you of the nature and substance of the recorded information; - 2. allow you to see and copy, in person, such recorded personal information; or - 3. send you a copy of the recorded personal information by mail. (We may charge you a reasonable fee to cover the cost of this service.)

We will also tell you at this time the identity, if recorded, of persons to whom we have disclosed the personal information within the preceding two years.

If you ask us to correct, amend or delete any information about you, we will within 30 days, either correct, amend or delete the personal information in dispute or notify you of our refusal to take such action along with the reasons for our decision.


If we make the correction, amendment or deletion you've requested, we will also notify you along with any person you designate who has received the information about you within the preceding two years, any insurance support organization(s) which provided us with the disputed information.

If we refuse to make the requested correction, amendment or deletion, you are permitted to file a concise statement setting forth what you think is the correct, relevant or fair information along with a statement of the reasons why you disagree with our refusal to correct, amend or delete the information subject to dispute. We will file your statement with the disputed personal information and make any person who reviews your file aware of your statement. We will also furnish your statement to any person who has received personal information from us with the two preceding years and any insurance support organization whose primary source of personal information is an insurer.

You should know that personal information obtained from a report prepared by any insurance support organization may be retained and disclosed to other persons in the future.

Please submit your request for additional information to:

AIG Property Casualty Company Private Client Group 175 Water St, 18th Floor New York, NY 10038