2021/06/14 Western A/V, Inc.PO Box 853922
Richardson, TX 75085-3922
76A
DATE OF NOTICE: JUN 14 2021
CODE:
S
N
AT 1 23
001181 0093
CITY OF MENIFEE
& IT'S OFFICERS, EMPLOYEES,
AGENTS, ISAOA
a� 29844 HAUN RD
ti MENIFEE CA 92586-6539
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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
3535-FB8ArA
NAMED INSURED: POLICY NO:
260 9254-E28-75K
COVERAGE:
WESTERN ASV INC YRIMAKE/MODEL:
2007 FORD PICKUP
HI AND PD LIABILITY
1592 N BATAVIA ST STE 2 VIN/CAMPER:
1 FTRW12W27FAi2672
$1 $200MIL
0 COMP. DE
ORANGE CA 92867-3554 AGENT NAME:
.
DENISE K HUDSON INS AGCY INC �A00 DEDD. COC7OL,LL.
AGENT PHONE:
(114)633-6118
ENDORSEMENT NO:
6028BU
POLICY EFFECTIVE
JAN 28 2021 UNTIL TERMINATF-n
POLICY MESSAGES: This policy shown above supersedes policy# 2609254-75J.
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 20 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