MACDONALD, SYBIL ALICIA - 2016 - Laserfiche WebLink

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ACCII, bW VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DATE (MMIDD YYYY) 09/26/2016 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 form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER CONTACT NAME: HAMPTON StateFann SINNER INSURANCE AGENCY, INC 6535 WILSHIRE BLVD SUITE 117 AICNNo EM; 323-651-4775 plc ND: 323-651-3291 E-MAIL ADDRESS: LOS ANGELES, CA 90048 PRODUCER CUSTOMER ID q: INSURER(S) AFFORDING COVERAGE NAIC9 DATE IMMIDDIYYYYI INSURED INSURERA: State Farm Mutual Automobile Insurance Company 25178 INSURER B: STEVE & SYBIL A MACDONALD INSURER C: 6381 LINDENHURST AVE INSURER D: LOS ANGELES, CA 90048-4729 INSURER E: BODILY INJURY (Per person) DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR 2003 MAKE I MANUFACTURER LEXUS MODEL LS430 BODY TYPE 4DR VEHICLE IDENTIFICATION NUMBER JTHBN30F430098596 DESCRIPTION listed herein b olic numbers. SERIAL NUMBER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCY(IES) OF INSURANCE LISTED BELOW HAS/HAVE 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 POUCY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR ADD'L listed herein b olic numbers. POLICY EFFECTIVE POLICY EXPIRATION NAME AND ADDRESS OF ADDITIONAL INTEREST LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDiri DATE IMMIDDIYYYYI LIMITS Santa Ana, CA 92701 X VEHICLE LIABILITY COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ 1,000,000 4003551-D20-75 09/26/2016 10/20/2017 BODILY INJURY (Per accident) $ 1,DDD,000 PROPERTY DAMAGE $ 1,000,000 GENERAL LIABILITY EACH OCCURENCE $ OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE $ INSR LOes POLICY EFFECTIVE POLICY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYYYY) DATE(MMIDDIYYYYI LIMITS/ DEDUCTIBLE X VEH COLLISION LOSS I] ACV ❑ AGREED AMT It LIMIT E]❑ STATED AMT $ 500 DED X VEH COMP VEH OTC I] ACV ❑ AGREEDAMT $ LIMIT ❑ ❑ STATED AMT $ 1000 DED PROPERTY ❑ ACV ❑ AGREED AMT $ LIMIT BASIC BROAD RC ❑ ❑ BTATEDAMT $ DED SPECIAL ❑ X ERS REMARKS (INCLUDING SPECIAL CONDITIONS / OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ADDITIONAL INTEREST CANCELLATION v Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED X The additional interest described below has been added to the pclicy(ies) listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE A request has been submitted to add the additional interest described below to the pollcy(ies) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. listed herein b olic numbers. VEHICLE I EQUIPMENT INTEREST: LEASED FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST X ADDITIONAL INSURED LOSS PAYEE NAME AND ADDRESS OF ADDITIONAL INTEREST X LENDER'S LOSS PAYEE EMPLOYER David Cavazos, City Manager LOAN I LEASE NUMBER The City Of Santa Ana AUTHORIZED REPRESENTATIVE Santa Ana, CA 92701 ©1997-2010 ACORD CORPORATION. All rights reserved. ACORD 23 (2010105) The ACORD name and logo are registered marks of ACORD 1004361 142987,2 01-28-2013