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StateFarm STATE FARM <br />PO Box 853922 <br />Richardson, TX 75085-3922 <br />66A <br />ATi 23 <br />0009M 0093 <br />CITY OF SANTA ANA, ISAOA <br />20 CIVIC CENTER PLZ FL 4TH <br />SANTA ANA CA 92701-4058 <br />Itr111111111111111[[1111111.1111111111 IgDll 4111, 1111 1111 111111 <br />DATE OF NOTICE: DEC 04 2019 <br />CODE: <br />NOTE: PLEASE NOTIFY STATE FARM AT THE <br />ADDRESS LISTED AT THE TOP, LEFT CORNER <br />OF THIS PAGE REGARDING ANY CHANGE OF <br />ADDRESS INFORMATION. <br />ADDITIONAL INISURED'S NOTICE OF COVERAGE <br />State Farm Mutual Automobile Insurance <br />Company <br />7501.FA4&A <br />NAMED INSURED: <br />POLICY NO: <br />441 4187-F24-75W <br />COVERAGE: <br />NANCY K BOHL INC <br />YRIMAKEIMODEL: <br />2017 BMW SPORT WG <br />B'AND PD Will LOY <br />DBA THE COUNSELING TEAM <br />VINICAMPER: <br />SUXKROC36HOU13705 <br />$I MIL IS i MIL Is 1 MIL <br />10 OED. COMP. <br />INTERNATIONAL <br />AGENT NAME: <br />SKALA INSURANCE AGENCY INC $00 <br />10e4 DED. COLL <br />PO BOX 10427 <br />AGENT PHONE: <br />(909)683-8861 <br />SN BERNRDNO CA 92423-0427 <br />ENDORSEMENT NO: 6026BU <br />POLICY EFFECTIVE <br />OCT 31 2019 UNTILTERMINATED <br />POLICY MESSAGES: This policy shown above supersedes policyY 4414187-75V <br />The policy includes a loss payable clause protecting the addi tonal insured's Interest In the described carts the extent of the insurance <br />provided and subject to all policy provisions. The additional Insured will be given 20 days notice If the policy is terminatedLlntil such notice <br />is provided, it shall be presumed that the required renewal premiums have been paid.The additional insured must notify us within 10 days of <br />any change of interest or ownership coming to their atlenlion.Fallure to do so will render this policy null and void, <br />FRT <br />REsI M91agYmnll DLwsl an <br />REVIEWED &APPROVED BY: <br />'� Risk Management Analyst <br />