VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE (2) F DATE
AC"R"® VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE 12/12/2023DD/YYYr)
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
one Y
Stat(2'Farfri Dan Pulaski PHOACNE Ext: 972-712-6000 FAX No:
1518 Legacy Drive Suite 200 E-MAIL ADDRESS: ed@danpulaski.com
(1010) Frisco,Texas 75034 PRODUCER
CUSTOMER ID#:
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: State Farm County Mutual Insurance Company of Tera 26816
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 $
A 576 3223-C07-43 09/07/2023 03/07/2024 BODILY INJURY(Per person) $ 1,000,000
BODILY INJURY(Per accident) $ 1,000,000
PROPERTY DAMAGE $ 1,000,000
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 576 3223-C07-43 09/07/2023 03/07/2024
❑ ❑ STATED AMT $ 500 DED
X VEH COMP VEH OTC ❑x ACV E]AGREED AMT $ LIMIT
A 576 3223-C07-43 09/07/2023 03/07/2024
❑ ❑ 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 576 3223-C07-43 09/07/2023 03/07/2024 $100/$300/$100
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
FThe 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 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