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StateFarm STATE FARM <br />M. <br />PO Box 853922 <br />Richardson, TX 75085-3922 <br />66A <br />AT1 23 <br />000939 0093 <br />CITY OF SANTA ANA, ISAOA <br />20 CIVIC CENTER PLZ FL 4TH <br />13, SANTA ANA CA 92701-4058 <br />Inllllllll�I���II��III��I!'�Ill�l����nlnll'I�liuil�l" �'I���� <br />DATE OF NOTICE: DEC 04 2019 <br />CODE: <br />NOTE: PLEASE NOTIFY STATE FARM AT THE <br />ADDRESS LISTED AT THE TOP, LEFT CORNER <br />OF THIS PAGE REGARDING ANY CHANGE OF <br />ADDRESS INFORMATION. <br />ADDITIONAL INSURED'S NOTICE OF COVERAGE <br />State Farm Mutual Automobile Insurance Company 7501-FA48-A <br />NAMED INSURED: POLICY NO: 441 4187-F24-75W COVERAGE: <br />NANCY K BOHL INC YRIMAKEfMODEL: 2017 8MW SPORT WG Bi AND PD LIABILITY <br />' DBA THE COUNSELING TEAM VINiCAMPER: 5VXKR6C36H0U13705 5 3 (30 DE 1 h COMP. S MIL <br />o $1000 DED. LL <br />'t' INTERNATIONAL AGENT NAME: SKAtA INSURANCE AGENCY INC r100@i]Ed. CALL <br />PO BOX 10427 AGENT PHONE: (909)883-8861 <br />o SN BERNRDNO CA 92423-0427 ENDORSEMENT NO: 60285U POLICY EFFECTIVE <br />c OCT 31 2019 UNTIL TERMINATED <br />m POLICY MESSAGES: This policy shown above supersedes policy# 4414187-75V. <br />The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance <br />o, provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminatedUntil such notice <br />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 />g any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void, <br />FRT <br />RAManagement Dtwalan <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />