HomeMy WebLinkAboutBIRKMEYER, DAVID & BETHANY - INSURANCE CERTIFICATE (3)u
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StateeFFarm STATE FARM°
PO Box 9009
Tempe, AZ 85281-9709
107
AT1 20
002932 0055
CITY OF FORT COLLINS
ATTN: PURCHASING
PO BOX 580
= FORT COLLINS CO 80522-0580
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DATE OF NOTICE: FEB 05 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.
NOTICE OF TERMINATION OF AN ADDITIONAL INSURED INTEREST'
State Farm Mutual Automobile Insurance Company 1069-FC15-A
NAMED INSURED: POLICY NO: 017 0829-Bo6-501 COVERAGE:
BIRKEMEYER, DAVID & BETHANY YR/MAKE/MODEL: 2007 DODGE PICKUP
121 US HIGHWAY 85 VIN/CAMPER: 1D7KS28C37J509443
CHEYENNE WY 82007-9646 AGENT NAME: ALAN OSE
AGENT PHONE: (307)778-7770
3RD PARTY INTEREST TERMINATED
EFFECTIVE FEB 18 2018
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.