HomeMy WebLinkAboutBIRKEMEYER, DAVID & BETHANY - INSURANCE CERTIFICATE (2)State&rm STATE FARM®
PO Box 9009
Tempe, AZ 85281-9709
DATE OF NOTICE: FEB 14 2017
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138A
AT1 20
001213 0093
CITY OF FORT COLLINS
ATTN: PURCHASING
PO BOX 580
FORT COLLINS CO 80522-0580
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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
1069-FC15-A
NAMED INSURED: POLICY NO:
017 0829-806-50G
COVERAGE:
BIRKEMEYER, DAVID & BETHANY YR/MAKE/MODEL:
2007 DODGE PICKUP
BI AND PD LIABILITY
121 US HIGHWAY 85 VIN/CAMPER:
ID7KS28C37J509443
$100,DIED. OMP./$100,000
$500 DIED. COMP.
CHEYENNE WY 82007-9646 AGENT NAME:
ALAN OSE
$500 DIED. COLL.
AGENT PHONE:
(307)778-7770
ENDORSEMENT NO:
6028BJ
POLICY EFFECTIVE
FEB 08 2017 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 0170829-50F.
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