2022/11/20 Coplenas,Jacob DBA SAFEUSA (4)StataFarrm. 5TATE FARM@&"DATE OF NOTICE: OCI 19 2022
CODE:PO Box 2368
Bloominglon lL 6 1 702-2368
854AT1 12
r)005i1 m93
THE CITY OF HENIFEE, ISAOA29844 HAUN RD
t'tEN I FEE CA 9?5A6-6539
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDBESS LISTED AT THE TOP, LEFT CORNEF
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFOBMATION.E*
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ADDITIONAL INSUBED'S NOTICE OF COVERAGE
Slate Farm Mutual Automobilo lnsurance CompFny. , 618F-FA96A
NAMEO INSURED: POLICV NO: 442 2o23-e2o.55E cAR oo5 COVEBAGE:
COPLENAS, JACOB DBA SAFEUSA YR/MAKE/MODEL: 2OO2 ISUZU BOX TRK BIANO PD LIABILIryi !0.s9111o-ulirm ew - --- vtN/CAMiEi: qxLg+erRgzJaozsas 3,l|itJgJ 35,i'rl "I ONTARIO CA 91762-2114 AGENT NAME: ZACH BAY INS AND FIN SVCS INC 6tooo oeo. coLL.H AGENT PHONE: ,tg0\221-3224
I ENDoRSEMENT No: 6o28BU PoLtcY EFFECIVE6 NOV 20 2022 UNTIL TERMINATED
E POLICY MESSAGES: This policy shown above supersedos policy, 4422023-55D.? The policy includes a loss payable clause protecting the additional insur€d's interest in the described car to ths exlent ot the insuranc€
E provid€d and subject to allpolicy provisions. The additional insured willbe given 20 days notice il the policy is lerminaled. Until such nolice
; is provided. il shall be presumed that lhe required renewal premiums have been paid. The addilional insured must notity us within 10 days oig any chanoe ol interest or ownership coming lo their attenlion. Failure to do so will render lhis policy null and void.
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ADDITIONAL INSUBED'S NOTICE OF COVERAGE
Slale Farm Mulual Automobile lnsurance Company 618F'FA9FA
NAMED INSURED: POLICY NO: 442 2023-E2a-55E CAB 010 COVERAGE:
COPLENAS, JACOB DBA SAFEUSA YH/MAKFJMODEL: 1998 1SUZU NOC TRK BIAND PD LIABILIry
1O3O N MOUNTAIN AVE VIN/CAMPER: JALg4Bl K5W7OOO552 $ ] MlL i $ 1 MIL /$ 1 MIL
oNTARro cA s1762-2114 AGENT NAME; ZACH BAY INS AND FIN SVCS INC s1000 DEo' coMP
IGEHT FHOflg' 130)221'3224 s1000 DED coLL'
ENDORSEMENT NO: bo2dBu POLICY EFFECTIVE
NOV 20 2022 IJNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedss policy* 4422023"55D.
The policy includes a loss payable clause protecling the additional insured's interest in the described car lo the extent of the insurance
provided and subject lo all policy provisions. The addilional insured,,yill be given 20 days notice il the policy is terminaled. Until such notice
o rs provrded, tt shall be presumed that ths required renewal premiums have been paid. The additional insured must noliry us within 10 days 0l
fi any cnange ol interest or ownership coming to thelr attenlion. Failure lo do so will render lhis policy null and void.
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ADDITIONAL INSUFED'S NOTICE OF COVEBAGE
Slale FaIm Mulual Aulomobile lnsurance Company 618F-FA96A
NAMED INSURED: PoLIcY No: 442 2023.E2o.55E CAR 013 COVERAGE:
COPLENAS, JACOB DBA SAFEUSA YR/MAKE/MODEL: 2OO7 APACHE TRL UTIL $1OOO OED, COMP.
1o3o N MOUNTATN AVE vitUcAlliEn: 5JRUE15277CO11649 $1000DED coLL'
ONTARIOCA 91762.2114 AGENT NAME: ZACH BAY INS AND FIN SVCS INC
AGENTPHONE: 1530)221-3224ENDORSEMENT NO: 6O28BU POLICY EFFECTIVE
NOV 20 2022 UNTIL TERMINATED
POLICY MESSAGES: This policy shown abov€ supersedes policy# 4422023-55D.
The policy inctudes a loss payable clause proteclino th€ additional insured's interesl in the described car to ths exlent ol lhe insurance
provided and subject to all policy provisions. The additional insured will be given 20 days notice ii lhe policy is lerminaled. Until such nolice
^ rs provided, il shall be presumed thal lhe required renewal premiums havs been paid. The addilional insured musl noiily us within 10 days ol
any change ol interest or ownership comino 10 their attention. Failure to do so will render lhis policy null and void.
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ADDITIONAL INSURED'S NOTICE OF COVERAGE
Stats Farm Mutual Automobils lnsurance Company 618F-FA9+A
NAMED INSURED: poLtcy No: 442 2023"E20-55E CAR 015 COVEBAGE:
COPLENAS,JACOB DBASAFEUSA YR/MAKEiMODEL: NONOWNED AUTO Bt ANo pD LtABtLtTy
1030 N MOUNTAIN AVE VIN/CAMPEH: $ 1 MIL/$ 1 MlLi$ 1 l\JlL
ON'rAR|O CA s1762-2114 AGENT NAME: ZACH BAy tNS AND FtN SVCS tNC $s00 DED. coMP/coLL.
AGENTPHONE: t53O)221-3224ENDORSEMENT NO: 6028BUoroiBE oroscs i3U:Jr'JIff,lif ,EHM,NATEDPOLICY MESSAGES: This policy shown above supersedes poticyt 4422O23-SSD.
The policy includes a loss payable clauso proiecting the additional insured's inlerest in the described car lo the exlenl ol the insuranceprovidod and subiecl to all policy provisions. The additional insured will be given 20 days nolice if lhe policy is lerminaled, Until such noticeis provided, it shall be presumed thal lhe required r€newal premiums hav€ been paid. The additional insured must notity us within 1O days ofany change of inler€st or ownership com ing lo their attention. Failure lo do so will render this policy null and void.
ADDITIONAL INSUFED'S NOTICE OF COVEBAGE
Slate Farm Mulual Aulomobile lngurance Company 61BF-FA9GA
NAMED INSUBED: pOLtCy NO: 442 2oz3.E2o.5sE CAH o1s COVERAGE:COPLENAS, JACOB DBA SAFEUSA YR/MAKE/MODELi 2000 ISLJZU BOX TRK Bl AND PD LIABILITY
1030 N MOUNTATN AVE VIN/CAMPER: JALB4B 143Y7OOO54O $ 1 MrL/$ 1 MrL/6 1 MtL
oNrARrocA s1762.2114 aGEHi iiaME: 2acH env NSANDFtNSVcsTNc :]::PRER !914PAGENTPHONE: ts3o)221-3224ENDORSEMENT NO: bozeeu PoLICY EFFEoTIVE
NOV 20 2022 UN'TIL TEBMINATEDPOLICY MESSAGES: This policy shown above supersedes poticy# 4422023-55D.
The policy includes a loss payable clause protecting the additional insured's interest in the describod car io tho extent of the insurance
provided and subjecl to all policy provisions. The additional insured will be given 20 days nolice il the poticy is terminatsd. Until such notice^ is provided, il shall be presumed thal the required renewal premiums havebeenpaid. The addiliooal insured must nolily us within lOdaysof* any change ol intelesl or ownershrp com ing lo lherr attention. Failure lo do so will render this policy null and void.t
ADOITIONAL INSUBED'S NOTICE OF COVERAGE
State Farm Mulual Automobilo lnsurance Company 6i8F-FA9eA
NAMED INSURED: pOLtCy NO: 442 zoz3-E2o-ssE CARo25 COVERAGE:
copLENAS, JAcoB DBA SAFEUSA YR/MAKE/MODEL: 2or2 HrNo Box rRK Bt^ND pD LtABtLtry
1O3O N MOUNTAIN AVE VIN/CAMPER: 5PVNJ8JT9C4S53583 $ 1 MIL/$ 1 MIL/$ 1 MIL
oNrABrocA si762-2114 AGENTNAME: zecH eev rNsar.rDirNSVCS rNc lll99RFP 99lYPAGENTPHONE: ls3o)p21-2224ENDORSEMENT NO: 6o28BU poLtcy EFFECT|VE
NOV 20 2022 UNTIL TERMINATEDPOLICY MESSAGES: This policy shor/n above supersedes poticy# 4422023-SiD.
The policy includ€s a loss payable clause protecting the addilional insured's inlerest in lh€ described car lo the exlent ot lhe insuranceprovided and subjecl to all policy provisions. The additional insured will b6 given 20 days nolice if the poticy is terminated. Untit such notice
^ is providod, ilshallbe presumedlhat the required renewal premiums have been paid. The addilional insured must notity us within tO days of
E any chanoe ot inlerest or ownership com ing lo lheir attenlion. Failure to do so ',{ill render this poticy nult and void.Ig
ADDITIONAL INSURED'S NOTICE OF COVERAGE
Slalo Farm Mulual Automobile lnsurance Company 61BF-FA96A
NAMEO INSUFED: PoLIcY No: 442 2023.E20-55E cAR 027 CoVERAGE:
COPLENAS, JACOB OBA SAFEUSA YR/MAKE/MODEL: 2006 INTEBNATNL Box TRK BI AND PD LIABILITY
1030 N |\4OUNTA|N AVE VIN/CAMPER: 1 HTi!IMAAL56H 179685 $ 1 MIL/$ 1 MrL/6 1 MrL
ONTABIO CA 91762-2114 AGENT NAME: 2eiH gnv rNs nNo rIN SVCS INc I1R9: RER PR|\IPAGENTPHONE: ts3o)221-3224ENDORSEMENT NO: 6ozdeu poltcy EFFECIVE
NOV 20 2022 UNTIL TERMINATEDPOLICY MESSAGES: This policy shown above supersedes poticyt 44ZZO23-SSD.
The policy includes a loss payable clause protecting the addiiional insured's inlerest in th€ describ€d car to lhe extent ol lhe insurancep.ovided and subiecl to all policy provisions. The additional insured will be given 20 days notice il the poticy is terminaled. Until such notice
is providod, ilshallbe presumed that the required renewalpremiums have been paid. The additional insuied must notily us wilhin 1O days ot
any chang€ ol inlerest or ownershipcoming to lheir attention. Failur€ lo do so will render this policy null and void.
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StatcE rn STATE FARM@&"DATE OF NOTICE: OCT 19 2022
CODE:
NOTE: PLEASE NOTIFY STATE FABM AT THE
ADDHESS LISTED AT THE TOP, LEFT COBNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADORESS INFORMATION.
PO Box 2368
Bloomi ng lon I L 6 I 702 -2368
854
12
000531 0093
THE CITY OF HENIFEE, ISAOA29844 HAUN RD
HENrFEE CA 9?546-6539f*
e
ADDITIONAL INSUHED'S NOTICE OF COVERAGE
State Farm Mutual Aulomobile lnsurance Company 618F-FA9&A
NAMED INSURED: POLICY NO: 442 2023-E2O-558 CAR 029 COVERAGE:
COPLENAS, JACOB DBA SAFEUSA YR/MAKE/MODEL: 201 1 CRAFT TRLFLTBD $1000 DED. coMP
ro30 N MouNTATN AVE vitlldauiEnr i6szer zzog u r ezss $1000DEo coLL.
ONTARIO CA 91762-2114 AGENTNAME: ZACH BAY INS AND FIN SVCS INCAGENTPHONE: (s1o)221-3224
ENDORSEMENT NO: 6o28BU POLICY EFFECTIVE
NOV 20 2022 UNTIL TERI\,llNATED
POLICY MESSAGES: This policy shown above supersedes policy# 4422023-55D.
The policy includes a loss payable clause prolect ng the additional insured's inlerest in the described car lo the extenl of the insurance
provided and subiect to all policy provrsions. The additional insured will be given 20 days notice i1 the policy is lerm naled. Until such nolice
is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must nolily us within 10 days ol
any change ol interesl or ownership com ing to lheir atlenlion. Failure 10 do so will render this policy null andvoid.
ADDITIONAL INSUBED'S NOTICE OF COVERAGE
Stat6 Farm Mutual Aulomobile Insurance Company 618F-FA9GA
NAMED INSURED: POLICY NO; 442 2023.E2O.558 CAB 031 COVERAGE:
coPLENAs. JACoB DBA SAFEUSA YR/MAKE/MODEL: 2OO3 INTERNATNL BOX TRK BI AND PD LIABILIry
1030 N ITOUNTA1N AVE VIN/CAMPER: I HTt NAAL63Hs55755 $ 1 MIL /$ 1 lrrl i$ 1 MIL
oNrARro cA s1762-2114 AGENr NAME: zAcH BAY rNS AND FrN svcs rNC I]l33 REB 33i1'AGENTPHONE: 1530)221-3224ENDORSEMENT NO: 6O28BU POLICY EFFECTIVE
NOV 20 2022 UNTIL TEBMINATEO
POLICY MESSAGES: This policy shown above supersedes policyi 4422023-550.
The policy includes a loss payable clause prolecling the addilional insured's interesl in lhe described car lo lhe extenl oi the insurance
provided and subject io all policy provisions. The addilional insur€d willbo given 20 days nolice il ths policy is lerminated. Unlil such noiice
= rs provded, rt shall be presumed that lhe required ren€wal premiurns have been paid. The additional insured rnust noliry us wlthin 10 days o,
N any change ot tnteresl or ownership coming lo their aflenlion. Failure lo do so will render lhis policy null and void.I
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ADDITIONAL INSURED'S NOTICE OF COVERAGE
Slale Farm Mulual Automobilo lnsumnco Company 618F-FASGA
NAMED INSURED: PoLICY NO: 442 2023.E20.55E CAR 032 COVERAGE:
COPLENAS, JACOB DBA SAFEUSA YH/MAKE/MODEL: 1986 TNTERNATNL BOX TRK Bl AND PD LlABlLlw
10s0 N [rouNTArN AVE vtuldeuipn: 1 HTLDTVR7GHA66864 $ 1 l\4lL/$ 1 MIL/$ ] MIL
oNTARrocA s1762-2114 AGENTNAME: ZACH BAY rNS AND FrN svcs rNC 31333BEB.33lllAGENTPHONE: 1530)221-3224
ENDORSEMENT NO: 6O28BU POLICY EFFECTIVE
NOV 20 2022 UNTIL TERi,,lINATED
POLICY MESSAGES: This policy shown above supersedes policy* 4422023-550.
The policy includes a loss payable clause protecling lhe addilional insored s inleresl in lhe described car lo the extenl ol the rnsurance
provided and subjecl to allpolicy provisions. The addilional insured willbe given 20 days notice il the policy is lerminated. Until such notice
is provid€d, it shall be presumed that ihe required renewal premiums have been paid. The additional insured musl notiry us wlthin 10 days o,
any change ol inlerest or ownership coming lo lheir attenlion. Fail!re lo do so will render lhis policy null and void.
I
ADDITIONAL INSURED'S NOTICE OF COVEBAGE
Stale Farm Mutual Automobile lnsuranee Company 618F-FA9&ANAMEDINSURED: poLtcy No: 442 2023.E2A-55E CAA sZZ CoVERAGE:
COPLENAS, JACOB DBA SAFEUSA YR/MAKE/MOOEL:
1O3O N MOUNTAIN AVE VIN/CAMPER:
ONTARIO CA 91762-2114 AGENTNAME: ZACH BAY INS AND FIN SVCS INCAqENIPtloNEj ti3o)221-3224ENoOBSEMENT NO: 6028BU pOLtCy EFFECT|VE
poLlcy MESSAGES: Nov 20 2022 UNTIL TERMINATED
The policy includes a loss payable clause protecling the additional insured s interest in lhe described car 10 the extenl ol the insuranceprovided and subject lo all policy provisions. The addilional insured will be given 20 days notice il lhe policy is terminated. Unlil such notice
is provided, it shali be presumed ihat the required renewal premiums have bee. paid. The addilional insured musl nolify us wilhin 1O days oi
any change of inleresl or ownership coming to their allention. Failure 1o do so wil render lhis policy nult and void.
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