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<br />(!j'^" .... <br />,~" <br />.> <br /> <br />STATE FARM' INSl1RANCE COMPANIES@ <br />.. <br />900 Old River Road <br />Bakersfield CA 93311-0001 <br /> <br />DATE OF NOTICE: FEB 152005 <br />CODE: <br /> <br />38A <br /> <br />A <br /> <br />R <br /> <br />CITY OF SANTA ANA CT <br />ATTN j CITY CLERK <br />20 CIVIC CENTER PLAZA <br />SANTA ANA CA 92701-4058 <br /> <br />NOTE: PLEASE NOTIFY STATE FARM AT THE <br />ADDRESS LISTED AT THE TOP, tEFT CORNER <br />OF THIS PAGE REGARDING ANY CHANGE OF <br />ADDRESS INFORMATION. <br /> <br />7 <br />6 <br /> <br />4 <br />3 <br /> <br />11.1....1.11...111......11.1..111....1.1.1..1...1.111.....1.11 <br /> <br /><Xl <br />o <br />o <br />8 <br />~ <br /> <br />ADDITIONAL INSURED'S NOTICE OF COVERAGE <br /> <br />State Farm Mutual Automobile Insurance Company <br />NAMED INSURED: POLICY NO: V541083-A15-75N <br />g HARTL,DAVID E & JOHNSON,JERENE YR/MAKE/MODEL: 2000 LEXUS 4DR <br />~ 3808 E LARKSTONE DR VIN/CAMPER: JT8BH28F3Y0177545 <br />::: ORANGE CA 92869-5355 AGENT NAME: TANYA PEARSON <br />AGENT PHONE: (714)289-1226 <br />ENDORSEMENT NO: 6028AU <br /> <br />8549-F418-M <br />COVERAGE: <br />BI AND PD LIABILITY <br />$ 1 MIL /$ 1 MIL /$ 1 MIL <br />$100 DED. COMP <br />$250 DED COLL. <br /> <br />,I ,Wi'~ <br />. it <br />~ <br /> <br />:> <br />GO <br />II: <br /> <br />.. <br />l::i POLICY MESSAGES: <br />:8 The policy includes a loss payable clause protecting the additional insured's 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 20 days notice if the policy is terminated. Until such notice <br />;d 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 />N any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. <br />on <br />C <br />C') <br />... <br /> <br />POLICY EFFECTIVE <br />JAN 10.2005 UNTIL TERMINATED <br /> <br />-," ) <br />.. .,~ .....~. <br />, <br /> <br />.-:-~ .. <br />; , ,- <br /> <br />~.? <br /> <br />.. - "~. . <br />v\;.c . <br />.1./ )'1..') . <br />'. ";...... ',-)./ .tU POk~1' <br />____-../.-,. '\: . .LY.l <br />--. "'-..;t I.., ; <br />,i;, "",,-,,,_~.~I c.:j,C~ <br />''''''I~ <br />. >"i""d! Ci;y ~i)eedY7'"--- <br />ttorl1ey <br /> <br />0.. <br /> <br />FRT <br /> <br />