HomeMy WebLinkAboutState farm Mutual Automobile Insurance Company 1
15DW1 05-11-1999 DECLARATIONS PAGE — 1 OF 3 MATCH 00111
STATE
® M
' STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
INSURANCE 31303 AGOURA ROAD WESTLAKE VILLAGE CA 91363
12
11 nY.XI A/y,9
70 ��Y-llY�iOLWIA�y0 04
POLICY NUMBER W27 8388—A24-75L e
9 00111
*** THE CITY OSANTA7ANA5&3THE6E
*C* SANTA ANA FINANCING AUTHORITY POLICY PERIO[MAY 03 1949TOJUL 24 1999 6
*0* THEIR OFFICERS , AGENTS & 3
*P* EMPLOYEES ATTN JEFF STEVENS 3
*Y* 20 CIVIC CENTER PLAZA STE M28
*** SANTA ANA CA 92701-4010 __
._ DO NOT PAY PREMIUMS SHOWN ON THIS PAGE,
N A M E D INSURED : ACTIVE PARTITIONS SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE.——
DESCRIBED YEAR MAKE MODEL BODY STYLE VEHICLE IDENTIFICATION NUMBER CLASS
VEHICLE 1997 FORD F350
PICKUP 1FTJW36G3VEA67677 1HOHO210
COVERAGES(AS DEFINED IN POLICY)
SYMBOL-PREMIUM-COVERAGE NAME LIMITS OF LIABILITY SEE REVERSE SIDE FOR IMPORTANT MESSAGE
A $209. 94 BODILY INJURY /PROPERTY DAMAGE LIABILITY
C LIMIT OF LIABILITY—COVERAGE A 1 ,000,000 EACH ACCIDENT
$21 . 32 MEDICAL PAYMENTS
LIMIT OF LIABILITY—COVERAGE C
EACH PERSON
D250 $67. 20 $250 DEDUCTIBLE COMPREHENSIVE
VE
G250 $127. 04 $250 DEDUCTIBLE COLLISION
H $1 . 73 EMERGENCY ROAD SERVICE
R1 $4. 82 CAR RENTAL AND TRAVEL EXPENSES
U $17. 11 UNINSURED MOTOR VEHICLE
LIMITS OF LIABILITY—U
EACH PERSON , EACH ACCIDENT
30 ,000
U1 $1 . 65 UNINSURED MOTOR VEHICLE PROPERTY DAMAGE0 ,000
ADDITIONAL USE OF NON—OWNED CAR COVERAGE
$2. 23 BIPD LIABILITY
$. 43 MEDICAL
$7. 20 PHYSICALPAYMENT DAMAGE
$460. 67 TOTAL PREMIUM FOR POLICY PERIOD MAY 03 1999 TO JUL 24 1999
$1023. 72 CURRENT 6 MONTH PREMIUM FOR JAN 24 1999 TO JUL 24 1999
THIS IS YOUR DECLARATIONS PAGE. CONTINUED
PLEASE ATTACH IT TO YOUR AUTO POLICY BOOKLET,
YOUR POLICY CONSISTS OF THIS PAGE,ANY ENDORSEMENTS,AND THE POLICY BOOKLET, FORM 9805. 5 PLEASE KEEP TOGETHER
REPLACED POLICY W278388-75K
M U T L V O L. 155-4976 CA.3
I
15DW1 05-11- 1999 DECLARATIONS PAGE
2 OF 3 MATCH 00110
STATE FARM
o STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
®'O
INSURANCE 31303 AGOURA ROAD WESTLAKE VILLAGE CA 91363
12
11 IXaX oXr)aftX, POLICY NUMBER W27 8388-A24-75L 8
10
7
9 00110 75-8533-116E 6
*** THE CITY OF SANTA ANA & THE POLICY PERIOIIMAY 03 1999 TO JUL 24 1999 5
*C* SANTA ANA FINANCING AUTHORITY
*0* THEIR OFFICERS , AGENTS & 3
*P* EMPLOYEES ATTN JEFF STEVENS 2
*Y* 20 CIVIC CENTER PLAZA STE M28 ,
*** SANTA A N A CA 9 2 7 01-4 010 DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. --
NAMED INSURED : ACTIVE PARTITIONS SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE.--
DESCRIBED YEAR MAKE MODEL BODY STYLE VEHICLE IDENTIFICATION NUMBER CLASS
VEHICLE 1997 FORD F350 PICKUP 1FTJW36G3VEA67677 1HOH0210
COVERAGES(AS DEFINED IN POLICY) SEE REVERSE SIDE FOR 1NF'ORTANT MESSAGr
SYMBOL-PREMIUM-COVERAGE NAME LIMITS OF LIABILITY
FXCEPTTONS A!UD FNDORSEMENTS
FINANCED- LASALLE NORTHWEST NATIONAL BANK , 4747 W IRVING PARK ROAD , CHICAGO
IL 60641-2764.
01 6028E . 5
NTA
ANA POLICE ADMIN IHOLDING SFACILITY IPROJECT , 1043OWP CIVIC ANY TCENTER DRTN BOB U STE S A201 ,
SANTA ANA CA 92703-2348 .
02 6028E . 5 ADDITIONAL INSURED-CRSS CONSTRUCTORS INC ATTN ROB THOMPSON SANTA
ANA POLICE ADMIN HOLDING FACILITY PROJECT , 1043 W CIVIC CENTER DR STE 200 ,
SANTA ANA CA 92703-2348.
03 6028E . 5 ADDITIONAL INSURED-THE CITY OF SANTA ANA & THE SANTA ANA
FINANCING AUTHORITY THEIR OFFICERS , AGENTS & EMPLOYEES ATTN JEFF STEVENS ,
20 CIVIC CENTER PLAZA STE M28 , SANTA ANA CA 92701-4010.
01 6037F . 11 CERTIFICATE OF INSURANCE-BECKMAN INSTRUMENTS ATTN : MIKE JARVIS ,
PO BOX 3100 , FULLERTON CA 92834-3100.
02 6037E . 12 CERTIFICATE OF INSURANCE-BECKMAN INSTRUMENTS , ATTN VIVIAN 2500
HARBOR BLVD , FULLERTON CA 92835-2600.
03 6037E . 12 CERTIFICATE OF INSURANCE-BUILDERS GUILD INC , ATTN : MINDY J
DUFFEL 4950 E INGRAM , MESA AZ 85205-3315 .
04 6037F . 11 CERTIFICATE OF INSURANCE-HUGHES RESEARCH LABORATORIES , ATTN :
LYNN JONES 3011 MALIBU CANYON RD , MALIBU CA 90265-4737.
05 6037F . 11 CERTIFICATE OF INSURANCE-TURELK , INC , FO BOX 93101 , LONG BEACH
CA 90809-3101 .
06 6037F . 11 CERTIFICATE OF INSURANCE-ENTERPRISE RENT-A-CAR ATTN : LEAH
GANDINGCO , 820 MALCOLM RD , BURLINGAME CA 94010- 1407.
6082AG . 1 AMENDATORY ENDORSEMENT : CHANGES-DEFINED WORDS ; FINANCED
VEHICLES ; INSURED ' S DUTIES ; COVERAGES AND CONDITIONS .
6289MM SINGLE LIMIT OF LIABILITY .
RESIDENCE-882 QUEENSDALE CIR , CORONA CA 91720 .
6049NN USE OF NONOWNED CARS - LIABILITY COVERAGES PHIL SUTHERLAND EFFECTIVE
9-7-95 .
6033C USE OF NONOWNED CARS - PHYSICAL DAMAGE COVERAGE , $25 ,000 LIMIT
APPLIES TO ITEM 3B , PHIL SUTHERLAND .
CONTINUED
THIS IS YOUR DECLARATIONS PAGE.
PLEASE ATTACH IT TO YOUR AUTO POLICY BOOKLET. 4
YOUR POLICY CONSISTS OF THIS PAGE, ANY ENDORSEMENTS, AND THE POLICY BOOKLET. FORM 9805. 5 PLEASE KEEP TOGETHER
REPLACED POLICY W278388-75K
M U T L V O L 155-4976 CA.3
I I
i I
15DW1 05-11-1999 DECLARATIONS PAGE — 3 OF 3 MATCH 00110
15TM:
CD STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
INSURANCE 31303 AGOURA ROAD WESTLAKE VILLAGE CA 91363
12
11 XAX KEXIf CV OM POLICY NUMBER W27 8388—A24-75L
9 00110 75-8533- 116E7
*** THE CITY OF SANTA ANA & THE POLICYPERIOcMAY 03 1999TOJUL 24 1999 56
*C* SANTA ANA FINANCING AUTHORITY
*0* THEIR OFFICERS , AGENTS & 4
*Y* 20P CIVIC SCENTERNPLAZA STEJEFFVM28 2
NS
*** SANTA ANA CA 92701-4010
_ DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE.--
DESCRIBED YEAR MAKE MODEL BODY STYLE VEHICLE IDENTIFICATION NUMBER CLASS
VEHICLE 1997 FORD F350 PICKUP 1FTJW36G3VEA67677 1HOH0210
COVERAGES(AS DEFINED IN POLICY)
SYMBOL-PREMIUM-COVERAGE NAME LIMITS OF LIABILITY SEE ilEVERSE SIDE FOR IMPORTANT MESSAGE
NAMED INSURED_ ACTIVE PARTITIONS INSTAI CATIONS INC 541 N MAIN ST STE 104-3n1
CORONA CA 91720-2055
THIS IS DECLARATIONS PAGE. AGENT :PLEASE ATTACH ITOUR TO YOUR AUTO POLICY BOOKLET. PHONE : (6 2 6)0 915—' ILL
6 6
YOUR POLICY CONSISTS OF THIS PAGE,ANY ENDORSEMENTS,AND THE POLICY BOOKLET. FORM 8533-414
REPLACED POLICY W278388-75K 9805 . 5 PLEASE KEEP TOGETHER
M U T L V O L 155-4976 CA.3