2022/11/20 Coplenas, Jacob DBA SAFEUSAstatofuin srarE FAHM@
PO gox 2368Bbonington lL 61 702-2368
120ATl 12
m3061 0055
THE CITY OF ].IENIFEE, ISAOA29844 HAUI| RD
ENIFEE CA 92586 - 6559
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DATE OF NOTICE: DEC 23 2022
CODE:
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGAROING ANY CHANGE OF
ADDRESS INFORMATION.
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NOTICE OF INSURANCE COVERAGE. ADDITIONAL INSURED
Slale Farm Mutual Automobile lnsurance Company 618F'FA9eA
NAMED INSURED: POLICY NO: 442 2023-E2o.55E CAR 032 COVERAGE:
COPIENAS, JACOB DBA SAFEUSA YRITIAKE/MODEL: 1986 INTERNATNL BOX TRK BIAND PD LIABILITY
1o3o N MouNrArN AVE vrnrdeuFEn: iiiiorvazcHnooeo+ s 1 MILi$ 1 Mrlis 1 MIL
ONTARIO CA 91762-2114 AGENT NAME: ZACH BAY INS AND FIN SVCS INC
AGE'{T PHoNE: (530)221'322a poLrcy RETNSTATED EFFECT,'E
NOV 20 2022 UNTIL TERMINATED
POLICY MESSAGES:
The additional inslredwillbB given 20 days notice it the policy is terminated. tinlil such notice is provid€d, il shall be presumed that the
required renewal pr€miums have b€€n paid. Th€ additional insur6d must nolity us within 10 days ol any chango ol interesl or ownership
comi.g lo their attenlion. Failure lo do so wtll rend€r this policy null and void.