American Family Connect Property and
Casualty Insurance Company
3500 Packerland Drive
De Pere, WI 54115-9070
Policy Number: AI03889836
California Mileage Verification
In accordance with Section 2632.5 (c)(2)(B)(i) of the California Code of Regulations
Name: Sonia Barsoumian
Albert Barsoumian
Please help us keep your policy accurate by completing this form and returning it to us.
Complete both boxes for each of the vehicles listed.
For your reference, according to the U.S. Department of Transportation Federal Highway Administration, the average
annual mileage in California is 13,636 miles.
VIN
2016/FORD/FUSION SE
3FA6P0HD6GR239940
2005/AUDI/A4 2.0T QUA
WAUDF68E35A462196
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Total Annual Mileage
(commute + pleasure)
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Current Odometer Reading
Email the completed form to servicepromise@connectbyamfam.com, send it by fax to 1-920-330-5607 or mail it to
CONNECT by American Family, P.O. Box 19054, Green Bay, WI 54307-9054.
I understand that the information provided will be used to validate my mileage. If I do not provide the requested
information within 30 days, my mileage may default to the 7,500 threshold, which may result in an increase in premium. I
understand that I will need to update this information upon subsequent renewals.
I certify that the information provided is accurate to the best of my knowledge. I understand that I may be asked for
additional documentation to substantiate my mileage estimate. I understand that I may be charged additional premium for
a policy term if my actual annual mileage for any vehicle is greater than what I represented above.
Signature
Date
This form is not a renewal offer.
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Vehicle Year/Make/Model
10/28/2020
American Family Connect Property and
Casualty Insurance Company
3500 Packerland Drive
De Pere, WI 54115-9070
Policy/Quote Number: AI03889836
NAMED DRIVER EXCLUSION ACKNOWLEDGEMENT
The undersigned acknowledges, understands and agrees to exclude coverage under the policy for the individual(s)
indicated below. The Named Driver Exclusion will become effective on the original policy inception date and
shall remain in effect for the term of the policy and for each renewal, reinstatement, substitute, modified or
replacement or amended policy, unless discontinued by us.
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Any future requests to add coverage for the individual(s) excluded must be requested by the named insured.
If you sign and date this offer to exclude, you must return it to the insurance company at the address listed above.
Name of Excluded Driver:
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Albert Barsoumian
Ara Barsoumian
Named Insured
Date
Named Insured (if more than one on the policy)
Date
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10/28/2020