2022/12/13 Act 1 Construction, Inc. (7)5T &FATM STATE FARM@&.
PO Box 2368Bloomington lL 6 1 702- 2368
DATE OF NOTICE: JAN 03 2023
CODE:
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNEH
OF THIS PAGE BEGARDING ANY CHANGE OF
AODRESS INFORMATION.
854
000999 0093CITY OF MENIFEE29844 HAUN RD
I'IEN r FEE CA 92586-6539ffi
3I
State Farm Mutual Aulomobile lnsurance Company 1o45-FACEA
NAIIIED INSUBED: PoLIcY No: 609 8506-Bo7-75G CoVERAGE:ACT 1 CONSTRUCTTON tNC YB/MAKEJMODEL: 2OO4 FORD ptCKUp 8lANo pD LtABtLtTy
444 6TH ST VIN/CAMPER: 1 FTR F 14544NC22020 31 MIL
NoRCo cA s2860-17s8 AGENT NAME: ror,tv rneervnr,r 33333 BEB.33[AGENTPHONE: {gos)942-6464
ENDORSEMENT NO: 6o28BU PoLIcY EFFECTIVE
OEC 13 2022 UNTIL TERI\,(INATEDPOLICY MESSAGES: This policy shown above supers6des poticy# 6098506-75F.
The policy includes a loss payable clause prolecling lhe additional insured's inter€sl in lhe described car to the extent ol the insuranceprovided and subiect lo all policy provisions. The addilional insurod will b€ given 30 days notice i, the policy is ierminated. Uniil such notice
is provided, il shall be pr€sumed that the required renewal premiums hav€ been paid. The additional lnsur€d must notiiy us within 1O days ot
any change ol interesl or ownership coming lo therr attention. Failure to do so will render lhjs poticy nullend void
ADDITIONAL INSUHED'S NOTICE OF COVEBAGE