ACCEPTED ANY_ALL AL 05.06.25-10.30.25.pdf
PDF 165 KB Posted
- Attached to
- Master Agreement AZ|CTR069161
- Contract number
- CTR069161
- Issued by
- Arizona
About this file
This document is a State Farm Mutual Automobile Insurance Company policy declarations page for a commercial vehicle insurance policy, involving K & K Systems Inc as the named insured, Summers Ins and Fin Svcs Inc as the agent, and the Arizona Department of Transportation (AZDOT) as an additional insured. The policy is specific to Mississippi, with the named insured located in Tupelo, MS and the agent located in Aberdeen, MS. The policy is marked as "ACCEPTED – AL Only" by ADOT Risk Management.
The policy covers a 2018 Dodge 3500 commercial flatbed truck with Vehicle ID Number 3C7WRSCL3JG325145. The insurance coverage includes Liability Coverage with a $1,000,000 limit per accident, Medical Payments Coverage with a $5,000 limit per person, Comprehensive Coverage with a $2,000 deductible, Collision Coverage with a $2,000 deductible, and Uninsured Motor Vehicle Coverage. The total premium for the policy period from May 06, 2025 to October 30, 2025 is $710.39, with a total renewal premium of $734.64 for the period from April 30, 2025 to October 30, 2025. The policy includes several endorsements, including provisions for additional insured status and waiver of subrogation in favor of AZDOT.
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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
290 1853-D30-24E
K & K SYSTEMS INC
687 PALMETTO RD
TUPELO MS 38801-7662
MAY 06 2025 to OCT 30 2025
VOL
MAY 30 2025
10464-2-A
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 000003 0058
00153/01149
IP
PD
M
AY
MATCH 00034
00034
A901E
NAMED INSURED
AGENT
Agent:
R
PHONE:
See Reverse Side 3262-BD4
24-3262-2 A
DECLARATIONS PAGE
12:01 A.M. Standard Time
MAY 30 2025
YOUR CAR
State Farm Mutual Automobile Insurance Company PO Box 2368 Bloomington IL 61702-2368
2018 DODGE 3500 3C7WRSCL3JG325145FLTBDTRK Commercial
SYMBOLS COVERAGE & LIMITS PREMIUMS
A $445.96 Liability Coverage Limit-Each Accident $1,000,000
C $4.60 Medical Payments Coverage Limit - Each Person $5,000
D $72.62 Comprehensive Coverage - $2,000 Deductible G $152.40 Collision Coverage - $2,000 Deductible U1 $34.81 Uninsured Motor Vehicle Coverage
Bodily Injury Limits Each Person, Each Accident $25,000 $50,000 Property Damage Limit Each Accident $25,000
$710.39Total premium for MAY 06 2025 to OCT 30 2025.
IMPORTANT MESSAGES
Replaced policy number 2901853-24D.
Your total renewal premium for APR 30 2025 to OCT 30 2025 is $734.64.
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)-AZDOT, 1655 W
JACKSON ST, PHOENIX AZ 85007-3217.
6018CY COMMERCIAL VEHICLE.
6030HN BUSINESS NAMED INSURED.
6125A AMENDATORY ENDORSEMENT.
6129AH AMENDATORY ENDORSEMENT.
6289CS SINGLE LIMIT LIABILITY COVERAGE.
6289DE SINGLE LIMIT UNINSURED MOTOR VEHICLE COVERAGE.
6196AA WAIVER OF SUBROGATION UNDER COVERAGE A ONLY IN FAVOR OF AZDOT.
000003 0058
ST
-1
-U
-9
Cindy Lewis AL Only
Page 1 of 1 6028BJ ©, Copyright, State Farm Mutual Automobile Insurance Company, 2005
6028BJ ADDITIONAL INSURED (Prior Notice Of Termination)
This endorsement is a part of the policy. Except for the changes it makes, all other provisions of the policy remain the same and apply to this endorsement.
1. A person or organization shown on the Declarations Page as an Additional Insured is provided Liability Coverage, but only to the extent that person or organization qualifies as an insured as defined in Liability Coverage.
2. An Additional Insured has the same right of recovery under Liability Coverage as if they had not been shown on the Declarations Page as an Additional Insured.
3. If Liability Coverage is changed or terminated as to the interest of the Additional Insured, we will provide the Additional Insured 10 days notice of such change or termination, unless another number of days notice is shown on the Declarations Page.
Policy Number 290 1853-D30-24E
Page 1 of 1 6196AA ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013
6196AA WAIVER OF SUBROGATION UNDER THE LIABILITY COVERAGE
This endorsement is a part of the policy. Except for the changes this endorsement makes, all other provisions of the policy remain the same and apply to this endorsement.
It is agreed that we have no right of subrogation under Liability Coverage against the person or or-ganization whose name is shown immediately following the title of this endorsement on the Decla-rations Page to the extent that you have waived your legal right to recover from that person or organization pursuant to a written contract you had duly executed with that person or organization prior to the accident or loss.
Policy Number 290 1853-D30-24E
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