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p.2 <br />nwn rover <br />CERTIFICATE OF INSURANCE <br />SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE <br />CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE <br />CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM <br />THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY <br />ANY POLICY DESCRIBED BELOW. <br />This certifies that STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois <br />? STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois <br />? STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas <br />? STATE FARM INDEMNITY COMPANY of Bloomington, Illinois, or <br />? STATE FARM GUARANTY INSURANCE COMPANY of Bloomington, Illinois <br />haa. nnvpraoe In force for the followina Named Insured as shown below: <br />NAMED INSURED: DROSMArr, TOM <br />ADDRESS OF NAMED INSURED: 17552 COTTONWOOD, IRVINE, CA 92612-2808 <br />POLICY NUMBER 252 5786-A25-75 75-F3-5096-9 <br />EFFECTIVE DATE <br />OF POLICY 07/25/10- 01/25/10 06/19/10-06/19/11 <br />DESCRIPTION OF 1991 MAZDA MX5 <br />VIN # PERSONAL <br />LIABILITY <br />VEHICLE (Inducting VIN) JV11NA351=1223250 UMBRELLA POLICY <br />LIABILITY COVERAGE ® YES ? NO ® YES ? NO ? YES ? NO ? YES ? NO <br />LIMITS OF LIABILITY <br />a. Bodily Injury <br />Each Person 5250,000 APPROVED FORM <br />Each Accident $500,000 <br /> <br />b. Property Damage 1,10 ET HER <br />Each Accident $100,000 <br />r- Bodily Injury & <br />Property Damage <br />Single Limit <br />Each Accident $1,000,000 <br />PHYSICAL DAMAGE <br />COVERAGES <br />® YES <br />? NO <br />? YES ? NO <br />? YES <br />? NO <br />? YES <br />? NO <br />a. Comprehensive $ 250 Deductible $ Deductible $ Deductible $ Deductible <br /> ® YES ? NO ? YES ? NO ? YES ? NO ? YES ? NO <br />b. Collision $ 250 Deductible $ Deductible $ DeductlNe $ Deductible <br />EMPLOYERS NON-OWNED <br />CAR LIABILITY COVERAGE <br />? YES <br />? NO <br />? YES ? NO <br />? YES <br />? NO <br />? YES <br />? NO <br />LIABILIIY <br />G <br />HIRED ? YES ? NO ? YES ? NO ? YES ? NO ? YES ? NO <br />VE <br />E <br />FLEET - COVERAGE FOR <br />ND <br />N D ? YES ? NO ? YES ? NO ? YES ? NO ? YES ? NO <br />MOTOR E <br />S <br />THE CITY OF SANTA ANA <br />20 CIVIC CENTER PLAZA <br />SANTA ANA, CA 92701 <br />AGENT 8644 08/31/2010 <br />Tithe <br />Rick Reed <br />1125 E 16°-" Street, Suite 7 <br />Upland, CA 91784 <br />Holder <br />INTERNAL STATE FARM USE ONLY: p Request permanent Certificate of insurance for liability coverage. <br />122429.3 Rev. 07,26-2005 ? Request Certificate Holder to be added as an Additional Insured.