HomeMy WebLinkAboutDONALD MAEZ - INSURANCE CERTIFICATE0
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State&rm STATE FARM®
PO Box 9009
Tempe, AZ 85281-9709
80A
AT1 20
000712 0093
THE CITY OF FORT COLLINS IT'S
OFFICERS, AGENTS & EMPOLOYEES
215 N MASON ST
FORT COLLINS CO 80524-4402
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DATE OF NOTICE: DEC 28 2018
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 1173-FC15•A
NAMED INSURED: POLICY NO: 055 2802-A26-50A COVERAGE:
MAEZ, DONALD YR/MAKE/MODEL: 2011 NISSAN VAN BI AND PD LIABILITY
232 STINSON AVE VIN/CAMPER: JN8AZ2KR3BT212141 $ 1 MIL /$ 1 MIL /$25,000
CHEYENNE WY 82007-1113 AGENT NAME: SUZANNE CORK INS AGCY INC
AGENT PHONE: (307)635-3773
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
DEC 19 2018 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 0552802-50.
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