HomeMy WebLinkAboutInsurance Certificate: Jeremy Holmes
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® DATE OF NOTICE: OCT 11 2016
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000835 009; NOTE: PLEASE NOTIFY STATE FARM AT THE
CITY OF ASHLAND ADDRESS LISTED AT THE TOP, LEFT CORNER
20 E MAIN ST OF THIS PAGE REGARDING ANY CHANGE OF
ASHLAND OR 47520-1850 ADDRESS INFORMATION.
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ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 2245-FAE6-A
NAMED INSURED: POLICY NO: 152 8700-F29-37F COVERAGE:
HOLMES, JEREMY YR/MAKE/MODEL: 2001 BUICK 4DR BI AND PD LIABILITY
$100,0001300,0001100,000
0 25 SUMMIT AVE VIN/CAMPER: 2G4WS52J911336240 COMPREHENSIVE
N MEDFORD OR 97501-2647 AGENT NAME: MANNY SAENZ $500 DED. COLL.
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AGENT PHONE: (541)770-2878
o ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
OCT 04 2016 UNTIL TERMINATED
N POLICY MESSAGES: This policy shown above supersedes policy# 1528700-37E.
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R 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 notity us within 10 days of
c any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
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