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7 State Farm Mutual Automobile Insurance Company <br />PO Box 2368 <br />Bloomington 1L 61702-2368 <br />NAMED INSURED 01000 <br />75-8127-4 A <br />001- <br />- <br />SIMMSGEIGER, MARIA 8 PATRICK <br />AND DIVERSIFIED WATERSCAPES, <br />INC <br />STE 213 <br />27324 CAMINO CAPISTRANO <br />LAGUNA NIGUEL CA 92677-1118 <br />❑O NOT PAY PREMIUMS SHOWN ON THIS PAGE. <br />IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED. <br />95788-4-A MATCH 01DOO MUTL VOL <br />DECLARATIONS PAGE <br />PAGE 1 OF 2 <br />POLICY NUMBER 628 3607-E09 75U <br />POLICY PERIOD JUL 17 2025 to NOV 09 2025 <br />12:01 A.M- Standard Time <br />STATE FARM PAYMENT PLAN NUMBER <br />1346356523 <br />AGENT <br />GARY BLACKBURN <br />23881 VIA FABRICANTE STE 506 <br />MISSION VIEJO, CA 92691-3139 <br />PHONE- (949)581-0800 <br />YOUR CAR <br />YEAR MAKE MODEL BODY STYLE VEHICLE iD. NUMBER CLASS <br />NONOWNF❑ <br />AUTO <br />670ADP0002 <br />SYMBOLS COVERAGE. & LIMITS r PREMIUMS <br />A liability Coverage H..k35.1 <br />Bodily Injury Limits <br />Each Person, Each <br />$1 ,00D,000 $1 ,000,000 <br />Property Damage,. <br />Each Accident <br />$1,000,000 <br />lJ Uninsured Motor Vehicle Coverages. <br />Bodily Injury Limits <br />Each Person, Each Accident <br />100.000 $300,000 <br />Total premium for JUL 17 2025 1161ft Ill 141. 99 This is not a hill, <br />IMPORTANT MESSAGES <br />IMPORTANT NOTICE <br />For your protection California law requires the following to appear with this policy. Any person who knowingly presents <br />false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is <br />fines <br />guilty of a crime and may be subject to and confinement in state prison. <br />Replaced policy number 6283607-75T. <br />Notice of insurance information collection practices - personal, family, or household insurance transactions: <br />We ma collect customer information from persons other than the individual or individuals applying for coverage. Such customer <br />information as well as other personal or privileged information subsequently collected may, in certain circumstances, be disclosed <br />to third parties without your authorization as permitted by law. <br />You have the right to submit a written request to access, correct, amend, or delete your personal information and the right to <br />receive a response wdhin 30 days of submitting your request. If we deny your request, you have the right to file a statement <br />with us containing the information you feel is accurate and fair along with the reasons you disagree with our denial. Instructions <br />on how to file such request and our full privacy notice can be found www.statetarm.com/oustomer-carelpiivacy-security/privacy <br />or contact your State Farm Agent. <br />Your total renewal premium for MAY 09 2025 to NOV 09 2025 is $228.28. <br />Location used to determine rate charged-29641 VIA CEBOLLA, LAGUNA NIGUEL CA 92677. <br />CONTINUED <br />08764107456 See Reverse Side <br />1 M-38M CA.2 95-2042 [o,ao�rlc( <br />11SXON (olooate) <br />