HomeMy WebLinkAbout583340 BROCC FRAMING INC - INSURANCE CERTIFICATE (2)Statee&rm STATE FARM®
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PO Box 853922
Richardson, TX 75085-3922
DATE OF NOTICE: NOV 02 2018
CODE:
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AT1 20
000792 0093
CITY OF FORT COLLINS
PURCHASING DEPARTMENT
PO BOX 580
FORT COLLINS CO 80522-0580
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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
2392-FAF1-A
NAMED INSURED: POLICY NO:
277 2986-C14-06C
COVERAGE:
BROCCOLI, BEN DBA BROCC YR/MAKE/MODEL:
2001 CHEVROLET BOX TRK
BI AND PD LIABILITY
FRAMING VIN/CAMPER:
1 GBJG31 R711173125
$ 1 MIL
$1000 DED. COMP.
5998 STONE CHASE CT AGENT NAME:
MOSKALSKI INS AND FIN SVCS INC $1000 DED. COLL.
WINDSOR CO 80550-8029 AGENT PHONE:
(970)493-1888
ENDORSEMENT NO:
6028BT
POLICY EFFECTIVE
SEP 20 2018 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 2772986-06B.
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 10 days notice if the policy is terminated. Until such notice
is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
FRT