HomeMy WebLinkAboutInsurance Certificate: Polaris Land Surveying LLCATE FAFM'
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PO Box 2358
Bloomington IL 61702-2358
84A
AT1 15
o01866 0093
THE CITY OF ASHLAND, ITS
ELECTED OFFICIALS, OFFICERS
& EMPLOYEES
51 WINBURN WAY
ASHLAND OR 97520-1849
11111111111111111111111111111111111111111111111111111111111111111
DATE OF NOTICE: FEB 28 2024
CODE:
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 090E-FAE6A
NAMED INSURED: POLICY NO: 090 4953-1309-371 COVERAGE:
POLARIS LAND SURVEYING LLC YR/MAKE/MODEL: 1999 TOYOTA PICKUP BI AND PD LIABILITY
$ 1 MIL /$ 1 MIL /$ 1 MIL
PO BOX 459 VIN/CAMPER: 4TAWN72NXXZ489828 $50 DIED. COMP.
ASHLAND OR 97520-0016 AGENT NAME: JON SNOWDEN INSURANCE AGCY INC $250 DIED, COLL.
AGENT PHONE: (541)482-2461
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
JAN 15 2024 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 0904953-37H.
Im 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
0 is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
g any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
ADDITIONAL INSURED'S NOTICE OF COVERAGE —71
State Farm Mutual Automobile Insurance Company 090B-FAE6A
NAMED INSURED: POLICY NO: L23 4521-D30-37L COVERAGE:
POLARIS LAND SURVEYING LLC YR/MAKE/MODEL: 2001 TOYOTA PICKUP BI AND PD LIABILITY
PO BOX 459 VIN/CAMPER: 5TEWN72N21Z728384 $ 1 MIL /$ 1 MIL /$ 1 MIL
ASHLAND OR 97520-0016 AGENT NAME: JON SNOWDEN INSURANCE AGCY INC $200 DIED.COOLL.
AGENT PHONE: (541)482-2461
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
JAN 15 2024 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# L234521-37K.
The policy includes a loss payable clause protecting the additional insured's 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 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
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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