2021/01/28 Western A/V, Inc.State&FM STATE FARMO
PO Box 853922
Richardson, TX 75085-3922
DATE OF NOTICE: FEB 01 2021
CODE:
72A
AT1 23
000957 0093
CITY OF MENIFEE
& IT'S OFFICERS, EMPLOYEES,
AGENTS, ISAOA
29844 HAUN RD
MENIFEE CA 92586-6539
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ADDITIONAL INSURED'S NOTICE OF COVERAGE
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
State Farm Mutual Automobile Insurance Company 3535-FB8AA
NAMED INSURED: POLICY NO: 260 9254-E28-75K COVERAGE:
WESTERN A/V INC YR/MAKE/MODEL: 2007 FORD PICKUP BI AND PD LIABILITY
1592 N BATAVIA ST STE 2 VIN/CAMPER: 1 FTRW1 2W27FA1 2672 $ t MIL
o ORANGE CA 92867-3554 AGENT NAME: DENISE K HUDSON INS AGCY INC $2000 DED. COMP.
o AGENT PHONE: (714)633-6118 $2000 DED. COLL.
o ENDORSEMENT NO: 6028BU POLICY EFFECTIVE
r JAN 28 2021 UNTIL TERMINATED
ro POLICY MESSAGES: This policy shown above supersedes policy# 2609254-75J.
9 The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
o provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
m is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
g any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
FRT