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AGENCY CUSTOMER ID: 1500 <br />LOC #: <br />ACC) ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br />AGENCY <br />Richard H. Vossmeyer, Agent <br />NAMED INSURED <br />VIDO SAMARZICH, INC. <br />6829 BILLINGS PL <br />RANCHO CUCAMONGA, CA 91701-4923 <br />POLICY NUMBER <br />See Remarks <br />CARRIER <br />State Farm Mutual Automobile Insurance Company <br />NAIC CODE <br />25178 <br />EFFECTIVE DATE: 12/05/2019 <br />ADDITIONAL REMARKS <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER:.. _ _ FORM TITLE: Additional Insured. <br />Policy Numbers: <br />456 4465-B05-75 <br />516 4139-EO9-75A <br />Additional Insured: The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701, it officers, employees, agents, and volunteers <br />Additional Insured's Notice of Coverage <br />State Farm Mutual Automobile Insurance Company <br />Policy Messages: The policy Includes a loss payable clause protecting the additional Insureds interest in the described car to the extent of the insurance <br />provided and subject to all policy provisions. The additional Insured will be given 30 days notice if the policy is terminated. Until such notice is provided, it shall <br />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 <br />coming to their attention. Failure to do so will render this policy null and void. <br />ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved <br />The ACORD name and logo are registered marks of ACORD <br />1004362 142991.1 01-21-2013 <br />