HomeMy WebLinkAboutTUMBLEWEED SUPER TASTY TREATS - INSURANCE CERTIFICATE (6)StateFaâ–º'm STATE FARM®
PO Box 9009
Tempe, AZ 85281-9709
22A
AT1 20
000979 0093
CITY OF FORT COLLINS
21 NORTH MASON
FORT COLLINS CO 80521
1111111 ll"IIIIIIIIIII'I'lllll'llllllll'lllllll"I I"II'llll'llll
A
DATE OF NOTICE: FEB 15 2017
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
1648-FAF1-A
NAMED INSURED: POLICY NO:
186 5209-A09-06C
COVERAGE:
AMMANN, DAVID YR/MAKE/MODEL:
2002 CHEVROLET VAN
BI AND PD LIABILITY
507 FOX GLOVE CT VIN/CAMPER:
1GNEL19X028130653
$ 1 MIL /$ 1 MIL /$100,000
FORT COLLINS CO 80524-2098 AGENT NAME:
RONNY BUSH
AGENT PHONE:
(970)484-3993
ENDORSEMENT NO:
6028BT
POLICY EFFECTIVE
FEB 13 2017 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 1865209-06B.
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