05-0727_HABITAT FOR HUMANITY_Certificate of Insurance OCERTIFICATE OF INSURANPE
SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE
CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE
CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM
THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY
ANY POLICY DESCRIBED BELOW.
This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois
❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois
❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas , or
❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois
has coverage in force for the following Named Insured as shown below:
NAMED INSURED: HABITAT FOR HUMANITY OF ORANGE COUNTY
ADDRESS OF NAMED INSURED: 2165 S GRAND AVE, SANTA ANA CA 92705
POLICY NUMBER 009 5264-EO9-75C 064 0840-F24-75A 129 3680-DOl-75
EFFECTIVE DATE
OF POLICY 05/09/05-05/09/06 06/24/05-06/24/06 04/01/05-04/01/06
89 FORD F250 PU 01 ISUZU STAKEBED 05 CHEVY
DESCRIPTION OF 1FTHF25G1KPB09323 4KLC4B1RllJ803809 SILVERADO
VEHICLE(Including VIN) 1GBJC34225E169282
LIABILITY COVERAGE ® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ❑ YES ❑ NO
LIMITS OF LIABILITY
a. Bodily Injury
Each Person
Each Accident
b. Property Damage
Each Accident
c. Bodily Injury R
Property Damage
Single Limit
Each Accident $1,000,000 CSL $1,000,000 CSL $1,000,000 CSL
PHYSICAL DAMAGE
COVERAGES M YES ❑ NO ® YES ❑ NO ® YES ❑ NO ❑ YES ❑ NO
a. Comprehensive $ loo Deductible $ 100 Deductible $ 100 Deductible $ Deductible
® YES ❑ NO ® YES ❑ NO ® YES ❑ NO ❑ YES ❑ NO
b. Collision $ 500 Deductible $ 500 Deductible $ 500 Deductible $ Deductible
EMPLOYERSNON-OWNED
CARLIABILITY COVERAGE [:1YES ❑ NO ❑ YES NO ❑ YES [:1 NO ❑ YES [:1 NO
HIRED CAR LIABILITY
COVERAGE ❑ YES ❑ NO ❑ YES ❑ [_1 [:1E:1NO YES ❑ NO YES NO
FLEET-COVERAGE FOR
ALL OWNED AND LICENSED YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
MOTO VEHICLES ❑
AGENT 8284 7/27/05
Signature ofAuthorized Repr sentative Title Agent's Code Number Date
Name and Address of Certificate Holder Name and Address of Agent
CITY OF SAN JUAN CAPISTRANO DIAN A. ROY
ATTN: MOLLY BOGH 2400 WEST COAST HIGHWAY STE 31
32400 PASEO ADELANTO NEWPORT BEACH CA 92663
SAN JUAN CAPISTRANO CA 92675 (949)631-5530
LIC# 0563196
INTERNAL STATE FARM USE ONLY: ❑ Request permanent Certificate of Insurance for liability coverage.
122429.2 Rev.06-10-2004 ❑Request Certificate Holder to be added as an Additional Insured.