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Nov - :i4 - 04 13 3 : 29p <br /> CERTIFICATE OF INSURANCE <br /> SUCH INSURANCE AS R SPECfS fHE INTEREST OF THE CERTIFICATE HOLDER WILL NOT BE CANCELED OR OTHERWISE <br /> K <br /> NITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED BELOW, BUT IN NO <br /> THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE <br /> ANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW.t: ® STATE FARM Mlj:'i JAL AUTCMOBILE INSURANCE COMPANY of Blacmiigion. ! Ilinoss <br />. cr <br /> .ATE FARM F! RE AND CASUA_"r COMPANY of Cloo, ringWri. 19incis <br /> harp cov5rage in force -or the foliowing ;Nemec Insured as shown below : <br /> Named onsurea St. Peter's 'Aissionary Baptist Ch ,irch Inc. <br /> Adc:ress of Named Insurea 4250 38 `N Avs . <br /> b'ero Beach . FL 32967 <br /> ap :i0y ntibtBcR 8402332C0955f QT 0534-A03.5 I " <br /> 9A I u73 5141 .327-59 1840 21!32•009. 59 <br /> EFFEC lVE DATE 0= 10,'09104.05109;'05 07f03/1441101105 08127.104.02127105 10r09104.04108105 <br /> j 1994 C'00GE 8350 VAN i 1981 INTEL BUS 11996 FORD ' 99A DODGE <br /> DESCRIPTICV OF ! E150 'JAN 8350 VAN <br /> VEHIC= ! <br /> LIZL1'Y COVERAGE SYEo ❑ NC L AYES ❑ NC '0YES ❑NO AYES ONO <br /> JWTS OF UA31LfT`.' -� - - '-- - — — <br /> 3. Bodily ; tiury <br /> I � <br /> "m Person I i <br /> e. BodiiyInjury <br /> Each Accident <br /> b. Prcper(y Camape i <br /> C. aadily .. niury & <br /> '. . . <br /> Froperty Damage S1 , D00 .000 . 00 31 000, D00.00 ( S1 , 000,000.00 S1 OOD, 000 .00 <br /> Single Lind Esr h 1 I ' <br /> Acc, dent _ <br /> = F,—`( SICAL DAMAGra �yES '--❑NG YES— —�NO 7- YES <br /> _ <br /> G ❑ NC AYES NQ <br /> t;OVERAGES $250 00 ocductibltr ! $23C .00 Deductible 1 $230 00 Deductible $250 00 De&0ble <br /> _ __ a. Comprbhrnsive _ _ __ � <br /> �x..IYES ❑ rio -� AYES ❑ NO i MYES ONO ( AYES No <br /> a. C�)[fsior! C500 • I;0 Deductible 600.0U Deductible I 500. 0 Deductible $500 -00 Deductible <br /> waft <br /> :MPLOYER'S <br /> CU <br /> COVERAGE ❑ Y =S y+J AYES EINC I ❑ YFS t1'0 ❑YES ANO <br /> HIRED CAR COVERAGE _jyes ONO oycES 'c NO UYES ONO Es <br /> Ager.: 2733 11104;'04 <br /> ignatu re of Au1~+orized Repr ntative TNotitle Ageni 's Cade Number ;Jets <br /> Name and Address of Cartificate Holder Name and Address of Agent <br /> David E . Hedges , Sia'-e Farm Insurance Agency <br /> Indian River County 2601 20" Street Suite 5 <br /> Vero Beach , FL 32960 <br /> Check Ka permanent Certificate cf insurance for liability .overage is needed : <br /> C; ieck if the Certificate Hotraei should be added as an Additional lasured: 71 <br /> 18514 :!o C F.v.. h}3i r'.trrtd] In L <br /> + 1 <br />