2022/12/13 Act 1 Construction, Inc.I sl.teE,?,, STATE FABM@&.
PO Box 2368Bloominglon lL 6 I 702-2368
AT1
DATE OF NOTICE: JAN 03 2023
CODE:
B4A
CITY O
MENIFE
000998 0093
ENIFEEA 9?546
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDBESS INFORMATION.
F t'tEC
ffi
h llr,llt, tllr,l, il r, th tt, h ltil t,l, t, t,llil h, t,,1ilil t,, tltlt
3
,J?
8
ADDITIONAL INSUBED'S NOTICE OF COVERAGE
State Farm Mulual Automobile lnsurance Company 1045-FACEA
NAMEO INSURED: PoLIcY No: 544 8080.B11.75G covERAGE:AcT 1 coNSTBUcTIoN INc YR/I,IAKE/MODEL: 2017 FoRD UTII TRK BI AND PD LIABILITY
444 6TH ST VIN/CAMPER: 1FTBW3BT0HED51452 s I MIL
NoRCo cA e2860-1758 AGENr NAME: ibr.rv rneevar,r 33333 BEB 33lilAGENTPHONE: {909)942-6464
ENDORSEMENT NO: dozeeu POLICY EFFEoTIVE
DEC 13 2022 UNT|L TERMINATEDPOLICY MESSAGES: This policy shown above supersed€s poticy* 5448080-75F.
The policy includes a loss payable clause protecting th€ ack ilional insured's interosl in th€ describ€d car to the extent oi th€ rnsurancsprovided and subject lo all policy provisions. The addilional insured will b€ given 20 days notice il the policy is lerminated. Until such notics
is provided, il shall be presum€d that lh€ requlred renewal premiums have b€en paid. The additional insured must notity us within 1O days ol
any change ol interest or ownership coming to lheir attenlion. Failure to do so tyill r€nder lhis policy nult and void.