HomeMy WebLinkAboutInsurance Certificate: Walter, Mark D & Christine L (2) Statefaim STATE FARM®
A. DATE OF NOTICE: DEC 01 2025
PO Box 2368 CODE:
Bloomington IL 61702-2368
14A
AT1 15 A
000688 0093
CITY OF ASHLAND NOTE: PLEASE NOTIFY STATE FARM AT THE
51 WINBURN WAY ADDRESS LISTED AT THE TOP, LEFT CORNER
rA ASHLAND OR 97520-1849 OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
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ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 95FA-FB621A
NAMED INSURED: POLICY NO: 410 4205-D03-37D COVERAGE:
WALTER,MARK D&CHRISTINE L YR/MAKE/MODEL: 2013 VOLVO 4DR BI AND PD LIABILITY
a IL
AGENT NAME: JEFF LANDSTROM $500 DIED.COLL.
AGENT PHONE: (503)518-7100
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
NOV 19 2025 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy#4104205-37C.
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
ca 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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ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 95FA-FB6ZA
NAMED INSURED: POLICY NO: 410 4205-D03-37D COVERAGE:
WALTER,MARK D&CHRISTINE L YR/MAKE/MODEL: 2013 VOLVO 4DR BI AND PD LIABILITY
AGENT NAME: JEFF LANDSTROM $5 DED.COMP.
AGENT PHONE: (503)518-7100 $�`0 0�DED.COLL.
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
NOV 19 2025 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy#4104205-37C.
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
p 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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