HomeMy WebLinkAbout541246 FRENCH CONCRETE INC - INSURANCE CERTIFICATE (7)StateFarm STATE FARM®
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PO Box 853922
Richardson, TX 75085-3922
123
AT1 20
003122 0055
CITY OF FORT COLLINS
DIRECTOR PURCHASING/RISK MGT
PO BOX
19
FORT COLLINSLI
CO 80522-0580
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DATE OF NOTICE: AUG 21 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.
''NOTICE OF TERMINATION OF AN ADDITIONAL INSURED INTEREST
State Farm Mutual Automobile Insurance Company 2531-FA65-A
NAMED INSURED: POLICY NO: 172 8428-A09-061- COVERAGE:
FRENCH CONCRETE INC YR/MAKE/MODEL: 1999 FORD FLATBED
PO BOX 193 VIN/CAMPER: 1 FDXW46FOXEC91947
MASONVILLE CO 80541-0193 AGENT NAME: DOUG BALDWIN
AGENT PHONE: (970)663-3684
3RD PARTY INTEREST TERMINATED
EFFECTIVE SEP 03 2017
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:
Unpaid premium of $450.45. 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.
FHT