HomeMy WebLinkAboutInsurance Certificate: Walter, Mark D & Christine L (3) I StateForm STATE FARM@
DATE OF NOTICE: SEP 01 2026
PO Box 2368 CODE:
Bloomington IL 61702-2368
25A
AT1 15 A
000743 Doss NOTE: PLEASE NOTIFY STATE. FARM T THE
CITY NB RN' WAY ANt3 ADDRESS LISTER AT THE TOP LEFT CORNER
AS LANBURN 975 OF THIS PAGE REGARDING ANY CHANGE OF
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ASHLAND OR 75 0-1�49 ADDRESS INFORMATION.
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ADDITIONA L INSURE 'S I OTIc of C 3vERAGE
State Farm Mutual Automobile Insurance Company 95FAxFB62-A
NAMED INSURED: POLICY NO:
AGENT NAME: JEFF LANDSTROM $ DED.COMP.
AGENT PHONE: (503)518-7100 $500 0 DED.COLL,
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
w AUG 24 2026 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy#4104205-37F.
The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
a 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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AUDITIONAL INSUREDS:::NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 9517A-171362�A
NAMED INSURED: POLICY NO:
AGENT NAME: JEFF LANDSTROM $ DED.COMP.
AGENT PHONE: (503)518-7100 $50 0 0 DED.DOLL:
ENDORSEMENT NO: 6028BJ POLICY EFFECTIVE
AUG 24 2026 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy#4104205-37F.
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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