HomeMy WebLinkAboutdoc03143820151118091123StageFarm STATE FARM®
0101 -ST --0000
900 Old River Road
Bakersfield CA 93311-9501
91A
AT1 02
000158 0093
TOWN OF TIBURON
1505 TIBURON BLVD
TIBURON CA 94920-2530
1111.111.1111111 1111. -110.1111111111111.1.,11.1.11111,111111111
A
DATE OF NOTICE: OCT 22 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.
RECEIVED
OCT 262015
TOWN (1 ANAGERS OFFICE
TOWN OF TIBURON
ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 2515-FAF2-A
NAMED INSURED: POLICY NO: 182 7401 -D09 -05H COVERAGE:
HARRISON, ROBERT YR/MAKE/MODEL: 2016 CHEVROLET 4DR BI AND PD LIABILITY
0 26 NEDS WAY VIN/CAMPER: 1G1RC6S59GU114407 $250,000/$500,000!$100,000
i TIBURON CA 94920-1580 AGENT NAME: SHEILA MACHADO $150 DED. COMP.
$250 DED. COLL.
ea
AGENT PHONE: (415)440-9984
G
ENDORSEMENT NO: 6028BU POLICY EFFECTIVE
OCT 20 2015 UNTIL TERMINATED
Fi POLICY MESSAGES: This policy shown above supersedes policy# 1827401-05G.
n The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
b provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
w 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 coning to their attention. Failure to do so will render this policy null and void.
0
FRT