HomeMy WebLinkAbout399025 CLEAN AIR LAWN CARE INC - INSURANCE CERTIFICATE (3)Sfafe&rm STATE FARM®
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PO Box 9009
Tempe, AZ85281-9709
DATE OF NOTICE: MAY 09 2019
CODE:
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AT1 20
CITY OF FORT
PO BOX 580
FORT COLLINS
23A
000830 0093
COLLINS
CO 80522-0580
11I11I1111111I1I11II1III111Jill I'1II1'1'I1
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
ADDITIONAL INSUIRED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company
2644-FAF1-A
NAMED INSURED: POLICY NO:
425 0861-C10-06D
COVERAGE:
REYNIER, JUSTIN YR/MAKE/MODEL:
2017 HONDA PICKUP
BI AND PD LIABILITY
321 DEL CLAIR RD VIN/CAMPER:
5FPYK3F58HB029719
$,o0.0001$100,000
$5000 DED.ED. COMP.
FORT COLLINS CO 80525-2512 AGENT NAME:
CHIP BEAKE INSURANCE AGCY INC $500 DED. COLL.
AGENT PHONE:
(970)482-1936
ENDORSEMENT NO:
6028BT
POLICY EFFECTIVE
MAY 07 2019 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 4250861-06C.
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