ACCEPTED AL ONLY 12.26.23-06.26.24.pdf
PDF 247 KB Posted
- Attached to
- Master Agreement AZ|CTR069161
- Contract number
- CTR069161
- Issued by
- Arizona
About this file
This document is an automobile insurance policy declarations page issued by State Farm Mutual Automobile Insurance Company for K & K Systems Inc, with Summers Ins and Fin Svcs Inc as the agent. The policy is specific to the state of Mississippi and includes an additional insured endorsement for the Arizona Department of Transportation. The policy period runs from December 26, 2023 to June 26, 2024, covering a 2017 RAM 2500 Pickup truck with Vehicle ID Number 3C6UR5HL4HG744654.
The policy provides liability coverage with limits of $1,000,000 per person and per accident for bodily injury and property damage. Additional coverages include $5,000 medical payments, emergency road service, and uninsured motor vehicle coverage with limits of $25,000 per person and per accident. The total premium for the policy period is $565.95, which includes liability coverage at $50.91, medical payments at $13.50, emergency road service at $4.85, and uninsured motor vehicle coverage at $46.69. The policy includes specific endorsements related to the Arizona Department of Transportation, such as prior notice of termination and a waiver of subrogation.
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Text version
155-3866.2 04-2005 (o1a025hd)
POLICY NUMBER
POLICY PERIOD
(o1a025te)
DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSE D.
YEAR MAKE MODEL BODY STYLE VEHICLE ID. NUMBER CLASS
Telephone:
Prepared (o1a0254c)
Date Countersigned
By
(o1a0255b)
I4SX2N
135 9395-F26-24E
K & K SYSTEMS INC
687 PALMETTO RD
TUPELO MS 38801-7662
DEC 26 2023 to JUN 26 2024
VOL
JAN 03 2024
04668-2-B
SUMMERS INS AND FIN SVCS INC
310 HIGHWAY 145 N
ABERDEEN, MS 39730-2310
(662)369-0337
SUMMERS INS AND FIN SVCS INC
(662)369-0337
MUTL
A 000005 0058
00356/04413
IP
PD
JA
N
MATCH 00168
00168
A901E
NAMED INSURED
AGENT
Agent:
R
PHONE:
See Reverse Side 3262-BD4
24-3262-2 B
DECLARATIONS PAGE
12:01 A.M. Standard Time
JAN 03 2024
YOUR CAR
State Farm Mutual Automobile Insurance Company PO Box 2368 Bloomington IL 61702-2368
2017 RAM 2500 3C6UR5HL4HG744654PICKUP 100H500000
SYMBOLS COVERAGE & LIMITS PREMIUMS
A $500.91 Liability Coverage Bodily Injury Limits Each Person, Each Accident $1,000,000 $1,000,000 Property Damage Limit Each Accident $1,000,000
C $13.50 Medical Payments Coverage Limit - Each Person $5,000
H $4.85 Emergency Road Service Coverage U1 $46.69 Uninsured Motor Vehicle Coverage
Bodily Injury Limits Each Person, Each Accident $25,000 $50,000 Property Damage Limit Each Accident $25,000
$565.95Total premium for DEC 26 2023 to JUN 26 2024.
IMPORTANT MESSAGES
Replaced policy number 1359395-24D.
State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile insurance is determined by many factors such as the coverages you have, where you live, the kind of car you drive, how your car is used, who drives the car, and information from consumer reports.
You have the right to request, no more than once during a 12-month period, that your policy be re-rated using a current credit-based insurance score. Re-rating could result in a lower rate, no change in rate, or a higher rate.
EXCEPTIONS, POLICY BOOKLET & ENDORSEMENTS (See policy booklet & individual endorsements for coverage details.)
YOUR POLICY CONSISTS OF THIS DECLARATIONS PAGE, THE POLICY BOOKLET -
FORM 9824A, AND ANY ENDORSEMENTS THAT APPLY, INCLUDING THOSE ISSUED TO YOU
WITH ANY SUBSEQUENT RENEWAL NOTICE.
6028BJ ADDITIONAL INSURED (PRIOR NOTICE OF TERMINATION)-ARIZONA DEPT OF
TRANSPORTATION, 739 W JACKSON ST, PHOENIX AZ 85007.
6030HN BUSINESS NAMED INSURED.
6129AH AMENDATORY ENDORSEMENT.
6196AA WAIVER OF SUBROGATION UNDER COVERAGE A ONLY IN FAVOR OF ARIZONA
DEPT OF TRANSPORTATION.
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