HomeMy WebLinkAboutdoc02717020150806115425StateFarmi STATE FARM®
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900 Old River Road
Bakersfield CA 93311-9501
97A
AT1 02
000172 0093
TOWN OF TIBURON
1505 TIBURON BLVD
TIBURON CA 94920-2530
111111111.1111.11111111111111.1111110H11.11,111111111,1111,0,1
A
DATE OF NOTICE: MAR 10 2015
CODE:
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company
NAMED INSURED:
HARRISON, ROBERT
26 NEDS WAY
TIBURON CA 94920-1580
POLICY NO:
YR/MAKE/MODEL:
VIN/CAMPER:
AGENT NAME:
AGENT PHONE:
ENDORSEMENT NO:
182 7401-009-05G
2013 CHEVROLET 4DR
1G1RE6E48DU100586
SHEILA MACHADO
(415)440-9984
6028BU
POLICY MESSAGES: This policy shown above supersedes policy# 1827401-05F.
n The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
co is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
o any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
2515- FA F2 -A
COVERAGE:
81 AND PD LIABILITY
$250,000/$500,000/$100,000
$100 DED. COMP.
$250 DED. COLL.
POLICY EFFECTIVE
MAY 06 2015 UNTIL TERMINATED
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FRT
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