HomeMy WebLinkAboutInsurance Certificate: Williams, Molly J .r..•....vr.rr 1 N 1 G rnnlvl-
OO® DATE OF NOTICE: MAY 16 2022
PO Box 2358 CODE:
Bloomington IL 61702-2358
22A
AT1 15 A
000999 0093 NOTE: PLEASE NOTIFY STATE FARM AT THE
CITY OF ASHLAND ADDRESS LISTED AT THE TOP, LEFT CORNER
20 E MAIN ST
O
ASHLAND OR 97520-1849 OF THIS PAGE REGARDING ANY CHANGE OF
��• �
ADDRESS INFORMATION.
IIIIIII'II11IIl1IIIIIIIIIIIIIIIII'VIII"VIII"III1ll'lll'II'1II
State Farm Mutual Automobile Insurance Company 2275-FAE6-A
NAMED INSURED: POLICY NO: 155 6519-C22-37G COVERAGE:
WILLIAMS,MOLLY J YR/MAKE/MODEL: 2012 FORD SPORT WG Bl/PD LIABILITY
1319 HARRISBURG DR VIN/CAMPER: 1FMCUOE72CKC19053 $100;000/$300,000/$100,000
MEDFORD OR 97501-8113 AGENT NAME: RUSSELL P BROWN INS AGENCY INC $100 DED.COMP.
$500 DED.LOLL.
AGENT PHONE: (541)776-8466
ENDORSEMENT NO: 6097BC POLICY EFFECTIVE
APR 29 2022 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy#1556519-37F.
The policy includes a loss payable clause protecting the additional insureds interest in the described car to the extent of the insurance
provided and subject to all policy provisions.The additional insured will be given 10 days notice if the policy isterminated. 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
any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
FRT