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Statefarm STATE FARM GENERAL INSURANCE COMPANY <br />❑ <br />A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON,ILLINOIS <br />' <br />RENEWAL_ DECLARATIONS <br />p <br />Bloomington IL 61702-2915 <br />Policy Number 90-E3-K8 <br />Addl insured -Section II Only <br />Policy Period Effective D � Expiration oats <br />OCT <br />AT2 M-12-2CC1-FB86 F U <br />000913 3125 <br />12 Months 15 21� OCT 15 2025 <br />CITY OF SANTA ANA <br />The poli y period begins and en 12:01 am standard <br />time atf�ie premises location. <br />ITS OFFICERS, OFFICIALS, <br />=M <br />EMPLOYEES & VOLUNTEERS <br />' 20 CIVIC CENTER PLZ <br />Named Insured t-; Q <br />SANTA ANA CA 9270I-4058 <br />MELGOZA, JORGE B � <br />Y. <br />g'�'IIII+IIIIiiiLllilll+IIIIIIII'IIII'l"II'I"I'II'IIIII'IIIII'I <br />" <br />0 <br />4 <br />O <br />O <br />Medical Office Policy " <br />Automatic Renewal - If the policy period is shown as 12 months , this policy will be renewed automatically subjectto the premiums, rules and <br />forms in effectfor each sllccLeding policy period. If this policy is terminated, we <br />will give you and the Mortgagee/Lienholder written notice in <br />compliance with the policy, provisions or as required by law. <br />Entity: Individual <br />NOTICE: Information concerning changes in your policy language is included. Please call your agent <br />if you have any questions. <br />POLICY PREMIUM <br />Discounts Applied: <br />Renewal Year <br />Sprinkler <br />Claim Record <br />$ 454.00 <br />Prepared <br />AUG 02 2024 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 <br />CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., smith its permission. <br />006408 294 Al Continued on Reverse Side of Page <br />N <br />Page 1 of 7 <br />SQtisag nc,qi_, , +77a= <br />