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StateFarm <br />State Farm Mutual Automobile Insurance Company <br />PO Box 2368 <br />Bloomington IL 61702-2368 <br />00711 <br />NAMED INSURED 000712 ooss 55-2CC1-3 A A <br />MELGOZA, JORGE B & MELGOZA, <br />ANNA <br />6867 GOLFCREST DR APT 51 <br />SAN DIEGO CA 92119-2444 <br />I:yk-1* ►yu_1061:<IIIYAS0kyil1iIIMM61I <br />I DECLARATIONS PAGE I <br />PAGE 2 OF 2 <br />POLICY NUMBER 583 7885-D15-55B <br />POLICY PERIOD FEB 24 2025 to OCT 15 2025 <br />12:01 A.M. Standard Time <br />STATE FARM PAYMENT PLAN NUMBER <br />1235506212 <br />YOUR POLICY CONSISTS OF THIS DECLARATIONS PAGE THE POLICY BOOKLET - <br />FOTH 9805ANY B�1BAND ANY <br />ENDORSEMENTS <br />NDORSEMEN ICEHAT APPLY, INCLUDING THOSE ISSUED TO YOU <br />01 6028BU ADDITTIONAL INSURED -CITY OF COSTA MESA, 77 FAIR DR, COSTA MESA CA <br />92626-6546. <br />02 6028BU ADDITIONAL INSURED -CITY OF SANTA ANA ISAOA, 30 CIVIC CENTER PLZ, <br />SANTA ANA CA 92701. <br />6125A AMENDATORY ENDORSEMENT. <br />6126MD EXCESS COVERAGE FOR PERSONAL VEHICLE SHARING. <br />6129J AMENDATORY ENDORSEMENT. <br />6196AA - WAIVER OF SUBROGATION UNDER THE LIABILITY COVERAGE FOR THE CITY <br />OF SANTA ANA ISAOA. <br />12961 /08381 <br />155-3866 CA.2 05-2002 (cla025fc) (cla0254c) <br />13SXO (cla025vd) <br />Agent: LAZARO INSURANCE AGENCY INC <br />Telephone: (619)229-6799 <br />Prepared MAR 12 2025 2CC1-B86 <br />