JOHNSON & VERCLIFF, LLC (2) - 2013

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o VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE YY' DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICY(IES) DESCRIBED 10111812013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this farm to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRUOU05R Sfdtefd/m JIM CONRAD AGENT STATE FARM INSURANCE 1056 BOLSA AVENUE SEAL BEACH, CA 90740 'IIIO'T JIM CONRAD PHDNs II No E :562 598-2415 ac xo : 562 431-4410 EMAIL ADD s: jim.conractloj2@staterfamn.com PROD CER CUS70MER 10 S: INSURERS AFFORDING CWERApE NAICM INSURED GARY E JOHNSON 120 3RD ST SEAL BEACH, CA 90740 INSURER A: State Farm Mutual Automobile Insurance Company 25178 INSURER IS: INSURER C INSURER D: INSURER E I nkGCRIDTInM nc vculnr c no c YEARMAKE I MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 2011 MERCEDES E350 4 DR WDDHF5GB5BA475118 DESCRIPTION SERIAL NUMBER COVFRaAFA r•coTlclnwTc sum.-.... _._.. ncV ualVry KVM®CK: THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HASIHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR LTR ADDL INMiD TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE IMMIODOYYYIO POMCYPAPIRATION DATE (MMlDOIYYYY) DMrS X VEHICLELIABIMTY COMBINED SINGLE LIMIT $ A 3806458 -BIS -75A 08/15/2013 02/15/2014 BCOILYINJURY IPerramoru $ 1,()00,000 BODILY INJURY (Paramount) S 1.000,000 • PROPERTYDAMAGE $ 1,000,000 GENERAL LIABILTrI' EACH OCCURENCE $ OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE INSR LTR Lose PAYEE TYPE OF INSURANCE POLICY NUMBER POUCYEFFECTIVE OATE(MMIDDIYYYYI POLICYE):PIRATION DATE(MMMO/YYYY) LIMITS/DEDUCTIBLE G VLH COLLISION LOSS ❑ ACV ❑ AGREED AMT $ LIMIT ❑ ❑ STATED AMT $ 1000 DED X VEH COMP VEH OTC D ❑ACV ❑ AGREED AMT S UNIT hgiROqED ASlO FORM ❑ ❑ STATED AMT $ 500 DED PROPERTY ACV 7] AGREED AMT BASIC BROAD ��„- \,{H„ O ❑ RC ❑ STATED AMI' f LIMIT SPECIAL _ �(? ..r..,..-.__._.... LIf DED L ,Assistant City Ailoiige\ REMARKS (INCLUDING SPECIAL CONDITIONS I OTHER COVERAGES) (Attach ACORD 101, Additional RemarMe Schedule, if more space Is required) AnnITIn MAI IMTPGGCT Sel1lct one of tho following: �4LLLXIIVIY X The additional irderesl tlescrihodbelax hssbaen Added to the pplicV(ies)listed herein by policy number(s). I'M rappue It has bean submitted to add ho additional inlorest described below to the policy(les) Ilsletlh Inb oli Abe s. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. VEHICLE1 EQUIPMENT INTEREST: LEASED 'X FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST ADDITIONAL INSURED LOSS PAYEE LENDER'S LOSS PAYEE LEINHOLDER NAME AND ADDRESS OF ADDITIONAL INTEREST MERCEDES -BENZ FINANCIAL INSURANCE SERVICES 13650 HERITAGE PKWY FORT WORTH TX 76177-5323. La SE NUMSER 1 i UTNO D RESTATI 1BBY-201U AGORD CORPORATION. AIM91I reserved. ACORD 23 (2010105) The ACORD name and logo are registers Zrks of ACORD 1004361 142987,2 01-28-2013