Insurance - Western A/V Inc- 2021-08-30M
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PO Box 853922
Richardson, TX 75085-3922
68A
AT1 23
000936 0093
COSTA MESA SANITARY DISTRICT
IT'S OFFICIALS, AGENTS, ISAOA
290 PAULARINO AVE
COSTA MESA CA 92626-3314
DATE OF NOTICE: AUG 30 2021
CODE:
SEP 0 7 2021
ADDITIONAL INSUREDS NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company
3535-PB8PrA
NAMED INSURED: POLICY NO:
708 1823 -F15 -75H
COVERAGE:
WESTERN AIV INC YR/MAKE/MODEL:
2021 FORD PICKUP
BI AND PD LIABILITY
1592 N BATAVIA ST STE 2 VIN/CAMPER:
1FTEWlCP7MFB37409
$ 1 MIL /$ 1 MIL /$ 1 $2000 DIED, COMP.MIL
ORANGE CA 92867-3554 AGENT NAME:
DENISE K HUDSON INS AGCY INC $2000 DED. COLL.
AGENT PHONE:
(714)633-6118
ENDORSEMENT NO: 6028BU
POLICY EFFECTIVE
AUG 26 2021 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 7081823-75G.
The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
FRT
-cata-teftM STATE FARM@
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PO Box 853922
Richardson, TX 75085-3922
68A
AT1 23
001049 0093
COSTA MESA SANITARY DISTRICT
290 PAULARINO AVE
COSTA MESA CA 92626-3314
DATE OF NOTICE: SEP 01 2021
CODE:
Fill 0) 11.11=331 ILI 1.1012n I XUlud
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ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company
3535-FB8ArA
NAMED INSURED: POLICY NO:
634 8561 -A27 -75F
COVERAGE -
WESTERN A/V INC YR/MAKE/MODEL:
2016 FORD VAN
BI AND PD LIABILITY
1592 N BATAVIA ST STE 2 VIN/CAMPER:
1 FTYR2CMOGKA1 0111
$1 MIL
$2000 DED. COMP,
ORANGE CA 92867-3554 AGENT NAME:
DENISE K HUDSON INS AGCY INC $2000 DED. COLL.
AGENT PHONE:
(714)633-6118
ENDORSEMENT NO:
6028BU
POLICY EFFECTIVE
AUG 31 2021 UNTIL TERMINATFD
POLICY MESSAGES: This policy shown above supersedes policy# 6348561-75E.
The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
FRT