HomeMy WebLinkAboutCOI - ALS Septic Tank Service - Expires 2022-06-2530(etWM STATE FARM`y
m
PO Box 853922
Richardson, TX 75085-3922
DATE OF NOTICE: SEP 03 2021
CODE:
20A
AT1 02
000205 0093
CITY OF GILROY ITS OFFICERS
OFFICIALS AND EMPLOYEES
••� PUBLIC WORKS DEPT
7351 ROSANNA ST
GILROY CA 95020-6196
"IIIII'I'Ill�llllllllllllll�lllllllll"'Illlllll�ll'�IIII�II'Il'
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
ADDITIONAL INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 3737-FBFF-A
NAMED INSURED: POLICY NO: 280 6213-F18-05L COVERAGE:
ELLIOTT SR, ALVIN J YR/MAKE/MODEL: 1997 KENWORTH TANK BI AND PD LIABILITY
c DBA ALS SEPTIC TANK SERVICE VIN/CAMPER: 1XKAD29X8VR729228 $too,000100,000/$100,000
$500 DIED. COMP.
N PO BOX 2225 AGENT NAME: ANDREW EDWARDS
c MORGAN HILL CA 95038-2225 AGENT PHONE: (408)782-3000
ENDORSEMENT NO: 6028BU POLICY EFFECTIVE
JUN 25 2021 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 2806213-05K.
co
The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance
o provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
g any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
FRT
O
N
O
H
Q
Uj CC LL
=WO
F- Z W
E- CC
.CCOZ
Ua
CC LL
<WU
LL J
w0 Q
�o�
Z
LL
oaaa
Z W CC cr
WF-WO
W J Q LL
Z
a
a�Ncn
WLu CC — W
H0�p
O0{Lp
Zaoa
to
Ix
W
U
H Ln
LL W
r, LL W %D
g 0 ��I
N J �D
rnH0- I
DREW. O
S WWF-N
} A N1 O
O A Ln
IYZVIQO%
_Latie Z
CDLn000
J3V)u
LL ¢ O
OHUW>-
U H O
}HJr-IfY
H LL W Lll ..I
HLL=MH
UOCLf`C0
W
0
I
U
LL
W
U
O
Z
LU
U)
Z
J
14
O
O
Q
O
O
LL o
0
w
m tF#
u Q8a:
¢
Z
Li.im(:��
ticr) �7,o0
�
Wa$w
w ~
000
> _
0Qoo
F- z
Um04
w
LL *-
fi
o
W N
U cm
J
OD
d --.)
Y
Z
~N0
J2Ncr-
LO 1- n ¢
00O>o0
LL3:XwM
CVj 0w00=
to^¢0aco
005 (j) x z
N ¢ �tp
O
J Z
W . f-
p wZZ
OCC UJOW
Zug. g z=aN
Y
CZ Z
L O
WWC
v Oa�> a<W
ar'
V
C
U)
C
� W
U
U-)E cr N
N
Q C7
Y p
¢
W Z� ¢
�p¢F J
N d u� J
w N —
Z � � N Z
U. W r-�X¢
:) 2 C)amEr
a Jmoo
cn Z woad
0
a� N
U 5,
C L O
c
� 3
�D�
o � .r-
ar-
(D :3
E O
N -0
'Q N _
U C C O
a) c
IZ
- O (a L
N a)
:E (n L
>' ~ -O
Y S 10 C7 c
U'lO a> N O L
a�cc3
(Daa)
O t'p)L
co 'o a) N
N >
_ m O
U c 3 w
o-a E
Q co ( .� 'co
o:3EL.L
jai CILc
�c��•E
c c
(n t p c ca
a) cu
� i
O> U O N
.Q N L
�16 BYO
3 a (n
O a)O
L in •- n) E
rn =3 N:s O
(9 > U
U U 2
o a)
acu20)a)
c
~M-�(n0
� Faa'-
WO O Q O
a(na)
—
w
cno-c�c
O O c —
w-0
c a>
Tea Ln
U0(D
Zi Q . O U
L
pa�oa>,
L i C
a P- a.Ln ca
0000-•1S- Lo t o
b z-90-90 (I lZ80e Lo) 8'000 LZ L
WCrLL
N
~ Z W
F-
QUQ
w
�
CC u- U
LL
Q
U)
W
LLI
LL J }
LL }
coJ
_z
a
~oZ
LL
r. Film
w Q
O
Z
�WZ
M O�
N N
UN CD
LL
O
>- O Z
cc a-
WO
>OQ
a= r- o
LU
Q
�Q�p
Z W 0
o
Ov
p Q
U m
_ � cnu Y
�' Q
zLo��
�>
WNwo
p
a` � s 2
aw
Qui JQ?
o�
-»
J N a cn
0 LL
� LL O cSf
w
o.U) �N
. w-w
ch
)
woo
o °'
ooLLOQ)
Y
w �
'+
Z<O<
a ODN
cm cn
f0 Z
J 2 Na
N
CO F- n Q
9ccoC3:o
�c
coo>po00
LL�XWM
Ua
Q-
cvYoWC
W
ornY0co
cc)Z O
N - -<
0 CD
W
`n
cu
It
ui
U
� 0
w
Q LLJ
z
c
_
Zw
a
za
L)
U �
—
L
C. Z
❑
W W
EOm
O aDV1
CL
,;V
w
aJ�U
> Q Q
. .�
s o
1-1 N
=
C
o
Q.
-0c�
LLW =
LO LL W �O -
a
lC
(D cc
$ O r-I —_
LL
y
13
> cc O
Nf-IED_
=
CDZ
d
�H
U
�
ai a)
o
o �z tnaa =
Q
E Ir N
Co
OC a
x
a�
wz
Z
"o� w a
U)�
.`>
O
L
LL
Fc-n
CDV)Oaa =
J 3 V) V —
a Y O
z cn
N (13
w >.0
O" CU W} -
W
F-
W Z F- Q
(} s
a
H
o
m
}" J r-1 w =
F- LL co Ln J
LL
7 J- U
= Q� J
a
Cn L
A--0 0
e
0 V
O
.- =
F- H LL O M H _
LLJ
LO J
E z� w N=
U)
LLU
O C a>
e
Q C
<L U O 0- F` C0 =
C.)
a. cA cV Zo
�0E-JXQ
�" Ocac
h
..
�
O
Z
20-Qm c
N Z woad
Jo c
an`_U E
0000--IS-lolo
noz-90-90 (aZ80eto) 8,0001z