HomeMy WebLinkAboutInsurance Certificate: Walter, Mark D & Christine L SfateF M STATE FARM®
m PO Box 2368 DATE OF NOTICE: OCT 16 2025
Bloomington IL 61702-2368 CODE:
45A
AT1 15 A
000721 0093 CITY OF ASHLAND NOTE: PLEASE NOTIFY STATE FARM AT THE
51 WINBURN WAY ADDRESS LISTED AT THE TOP, LEFT CORNER
ASHLAND OR 97520-1849 OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
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ADDITIONAL INSUREVS NOTICE OF COVERAGE 7771
State Farm Mutual Automobile Insurance Company 95FA-FB62'A
NAMED INSURED: POLICY NO: 410 4205-D03-37C COVERAGE:
WALTER,MARK D&CHRISTINE L YR/MAKE/MODEL:
AGENT NAME: JEFF LANDSTROM $500 DED.COMP.
AGENT PHONE: (503)518-7100
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
OCT 06 2025 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy#4104205-37B.
$ 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
CR 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.
ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 95FA-FBBLAA
NAMED INSURED: POLICY NO: 410 4205-D03-37C COVERAGE:
WALTER,MARK D&CHRISTINE L YR/MAKE/MODEL:
AGENT NAME: JEFF LANDSTROM $250 DED.COMP.
AGENT PHONE: (503)518-7100 $500 DED.COLL.
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
POLICY MESSAGES: This policy shown above supersedes policy#4104205-37B. OCT 06 2025 UNTIL TERMINATED
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 0 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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