HomeMy WebLinkAboutInsurance Certificate: Squeeky Clean W & EC INC
StateFarm STATE FARM@
DATE OF NOTICE: AUG 18 2016
PO Box 5000
Dupont WA 98027-5000 CODE:
57A
AT1 15 A
0007£$1 0093 NOTE: PLEASE NOTIFY STATE FARM AT THE
CITY OF ASHLAND & ITS ELECTED ADDRESS LISTED AT THE TOP, LEFT CORNER
OFFICIALS, OFFICERS & EMPLOYEE OF THIS PAGE REGARDING ANY CHANGE OF
20 ASHLAND OR 97520-1850 E MAIN ST ADDRESS INFORMATION.
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ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 2339-FAE6-A
NAMED INSURED: POLICY NO: 319 1175-A23-37B COVERAGE:
SQUEEKY CLEAN W & EC INC & YR/MAKE/MODEL: 1999 TOYOTA VAN BI AND PD LIABILITY
SCHREIBER, KIVA & HEATHER VIN/CAMPER: 4T3ZF13C8XU099397 $300,000,$300,000-$100.000
N $100 DED. COMP.
PO BOX 256 AGENT NAME: RUSS WMMER INS AGENCY INC $250 DED. COLL.
o TALENT OR 97540-0256 AGENT PHONE: (541)776-7877
o ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
AUG 15 2016 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 3191175-37A.
The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
o provided and subject to all policy provisions. The additional insured will be given 10 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
o any change of interest or ownership corning to their attention. Failure to do so will render this policy null and void.
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