HomeMy WebLinkAbout127666 MICHAEL TRUCKING - INSURANCE CERTIFICATE (17)02/28/2005 00:39 9704930226 CRAMER STATE FARM PAGE 01
A
CERTIFICATE OF INSURANCE
SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAZI
CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 16 DAYS PRIOR W
CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MO
THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE C
ANY POLICY DESCRIBED BELOW.
This Certifies that: ❑ STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of
® STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, It
❑ STATE FARM COUNTY MUTUAL. INSURANCE COMPANY OF TE)
❑ STATE FARM INDEMNITY COMPANY of Bloomington, Iginots
has coverage in force for the followino Named Insured as shown below.
BELOW WILLNNOT
rEN NOTICE TO 1
THAN 30 DAYS FRS
E"RAGtE PROVIDED
, Illinois
of Dallas, Texas, or
NAMED INSURED: Michael Dori t dba Michael Trucking
ADDRESS OF NAMED INSURED: 600 Endicott St., Fort Collins co 00524
POLICY NUMBER
S55 9543-A26-06A
055 2176--DOB-06F
EFFECTIVE DATE
OF POLICY
01/26/05-07/26/05
10/08/04-04/08/05
DESCRIPTION OF
83 Peterbuilt 359
97 Pet:erbuilt
VEHICLE (kICllydklp VIN)
1X 9D29XODP161U15
Dump
D3774171GL
LIABILITY COVERAGE
® YES Q No
® YES ❑ NO
❑ YES ❑ NO
❑ YES ❑ NO
LIMITS OF LIABILITY
a. Bodily Injury
$500,000
$500,000
Each Person
$500,000
$500,000
Each Accident
$500,000
$500,000
b. Property Damage
Each Accident
$500,000
$500,000
C. Bodily Injury &
Property Damage
Single IJmR
Each Accident
$500,000
$500,000
PHYSICAL DAMAGE
COVERAGES
® YES ❑ NO
® YES ❑ NO
❑ YFS ❑ NO
{,
❑ YES ❑ NO
a. Comprehensive
$ 2000 Deductible
$ 2000 Deducnde
$ 0educm
$ DeducHela
® YES ❑ NO
® YES ❑ NO
❑ YES [] NO
❑ YES ❑ NO
b. Collision
$ 2000 Dedudlble
$ 2000 Deductible
$ t>ertuoHbl
$ Deductible
EMPLANL r CARUy COVERAGE
❑ YES ® NO
❑ YES ® NO
❑ YES ❑ NO
❑ YES ❑ NO
HIRED CAR UABIUTY
COVERAGE
❑ YES NO
❑ YES ® NO
❑ YES ❑ NO
❑YES ❑ NO
FLEET -COVERAGE FOR
LICENSED
MQTO�R VVf NEDANp g
❑ YES NO
❑ YES ® NO
El ❑ NO
I
❑ YES ❑ NO
Licensed
1�'
Produce 1680 02/28/05
mature4Ads
R ative THIe Agents Comber Date
e anf Certificate Holder Name and Address of Agent
City of Fort Collins Cramer State Faun
PO Box 580 Gary Cramer
Fort Collins CO 80522 1275 E Magnolia 8T #1
Fort Collins Co 80529
INTERNAL STATE FARM USE ONLY: 0 Request Permenent Certificate of Insurance for Habliity coverage.
1224291 Rev. 0&10 JW4 0 Request Certftate Haider to be added as an Additional Inured.
I
OSTATE FARM INSURANCE COMPANIES®
1556 Promontory Circle
Greeley CO 80638-0001
150 A
CITY OF FORT COLLINS
300 LAPORT
FORT COLLINS CO 80521-2719
�Irr�r�lnu�r�ur�rinr�lulrllur�ur���r�n��ur��uulrlr�
DATE OF NOTICE: FEB 18 2005
CODE:
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
NOTICE OF TERMINATION OF A THIRD PARTY INTEREST' 1
State Farm Fire and Casualty Company 1680-FS25.1
NAMED INSURED: POLICY NO: 855 9643-A26-06G COVERAGE
MICHAEL, DWIGHT DBA MICHAEL
TRUCKING
600 ENDICOTT ST
FORT COLLINS CO 80524.3226
YR/MAKE/MODEL:
VINICAMPER:
AGENT NAME:
AGENT PHONE:
1983 PETERBUILT DUMP
1XP9D29X0DP161U15
GARY CRAMER
(970)484-1374
BI AND PD LIABILITY
3RD PARTY INTEREST TERMINATED
POLICY MESSAGES: EFFECTIVE MAR 03 2005
Protection of the third party's interest provided by this policy is terminated as of the effective date above for the following reason:
Cancellation of Liability Coverage. This advance notice is solely to protect the third party's interests as they are affected by the ownership,
maintenance, or use of the car described in the policy.
FRT