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VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE A�® VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE 08/02/02023 D ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. This form is used to report coverages provided to a single specific vehicle or equipment.Do not use this form to report liability coverage provided to multiple vehicles under a single policy.Use ACORD 25 for that purpose. PRODUCER CONTACT Ed Mahoney NAME:StateFar Dan Pulaski A/CNNo Ext: 972-712-6000 HOE A/c No: 1518 y Le ac Drive Suite 200 E-MAIL ADDRESS: ED DALPULASKI.COM Legacy Frisco,Texas 75034 PRODUCER VACVV2F CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: State Farm Mutual Automobile Insurance Company 25178 Randal Young INSURER B: 4001 Willow Hills Court INSURERC: ' Plano Texas 75024 INSURER D: INSURER E: DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE/MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 2021 Ram 2500 Pick Up 3C6UR5DL6MG611197 DESCRIPTION VEHICLE/EQUIPMENT VALUE SERIAL NUMBER 2021 Ram 2500 Pick Up-Crew Short-Big Horn $52,000 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES)OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S)INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICY(IES)DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR ADD•L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYYY) DATE(MM/DD/YYYY) LIMITS X I VEHICLE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 A Y 230801-43-7398-2021R 08/02/2023 02/02/2024 BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ GENERAL LIABILITY EACH OCCURENCE $ OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE $ INSR LOSS POLICY EFFECTIVE POLICY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YYYY) DATE(MM/DD/YYYY) LIMITS/DEDUCTIBLE X VEH COLLISION LOSS ❑x ACV ❑AGREED AMT $ LIMIT A 230801-43-7398-2021R 08/02/2023 02/02/2024 ❑ ❑ STATED AMT $ 500 DED X VEH COMP VEH OTC ❑x ACV E]AGREED AMT $ LIMIT A 230801-43-7398-2021R 08/02/2023 02/02/2024 ❑ ❑ STATED AMT $ 500 DED EQUIPMENT ❑ACV ❑AGREED AMT BASIC R BROAD ❑ RC ❑ STATED AMT $ LIMIT SPECIAL El DED X I UI BI UI PD A 230801-43-7398-2021 R 08/02/2023 02/02/2024 $500,000 CSL REMARKS(INCLUDING SPECIAL CONDITIONS/OTHER COVERAGES)(Attach ACORD 101,Additional Remarks Schedule,if more space is required) PIP Coverage:$2,500 ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED X The additional interest described below has been added to the policy(ies)listed herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE A request has been submitted to add the additional interest described below to the policy(ies) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. listed herein by policynumber(s). VEHICLE/EQUIPMENT INTEREST: LEASED FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST X ADDITIONAL INSURED R LOSS PAYEE City of Clearwater LENDER'S LOSS PAYEE 705 N Missouri Avenue LOAN/LEASE NUMBER Clearwater, Florida 33755 AUTHORIZED REPRESENTATIVE Completed by an authorized State Farm representative. If signature is required,please contact a State Farm agent. ©1997-2015 ACORD CORPORATION.All rights reserved. ACORD 23(2016/03) The ACORD name and logo are registered marks of ACORD 1004361 142987.4 04-24-2020