HomeMy WebLinkAbout399025 CLEAN AIR LAWN CARE INC - INSURANCE CERTIFICATE (2)StateFarm STATE FARM®
PO Box 9009
Tempe, AZ 85281-9709
DATE OF NOTICE: MAR 14 2019
CODE:
0
0
0
0
O
r
J
cm
A
0
co
d
0
0
N
AT1 20
CITY OF FORT
PO BOX 580
FORT COLLINS
123
003105 0055
COLLINS
CO 80522-0580
IIIII'I'I'lllll'I"'ll'l 11°I'lllllllllllllllllll'llll lllllilil'I
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 AN ADDITIONAL INSURED INTEREST
State Farm Mutual Automobile Insurance Company 2644-FAF1-A
NAMED INSURED: POLICY NO: 363 8801-005-06B COVERAGE:
REYNIER, JUSTIN YR/MAKE/MODEL: 2007 TOYOTA PICKUP
321 DEL CLAIR RD VIN/CAMPER: 5TENX22N87Z404700
FORT COLLINS CO 80525-2512 AGENT NAME: CHIP BEAKE INSURANCE AGCY INC
AGENT PHONE: (970)482-1936
3RD PARTY INTEREST TERMINATED
EFFECTIVE MAR 27 2019
POLICY MESSAGES:
Protection of the additional insured's interest provided by this policy is terminated as of the effective date above for the following reason:
Policy cancelled by insured. This advance notice is solely to protect the additional insured's interests as they are affected by the ownership,
maintenance, or use of the car described in the policy.
FRT