_GENERAL DOCUMENTS - C1981017 (198)

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CERTIFICATE OF INSURANCE SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED BELOW. BUT 1IL NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN_THIS CERTIFICATE OF INSURAIICE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This Certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomtrtgron. Illinois.or STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, IOinots has coverage to force for the following Named Insured as shown below: Named Insured Ward, Ray M. Address of Named Insured 30193 Highway 184 m Dolores, CO. 81323 POLICY NUMBER s66 5723-805-06J-0 1 EFFECTIVE DATE OF POLICY Feb. 05 98 DESCRIPTION OF VEHICLE 1984 Peterbi It LIABILITY COVERAGE U YES Q NO Q YES 0 NO YES [] NO Q YES I`I NO LIMITS OF LIABILriY 7 3 Soddy Irg�Y .. Eacfi Person Each A=ident 750,000 b. Property Danrdge Each A=*ett 750,,00Q, c &X*Irlury&Ropeny D'a TWe Single Lrrrit Each Adeident 750,000 PHYSICAL DAMAGE Q YES ® NO 7 YES Q NO U YES [J NO Q YES J NO COVERAGES a ! opTprehensNe $ Deductible S Deductible Deductiblc $ Deductibk, El YES r1 NO Q YES 0 NO w [ ]YES Q NO 0 YES Q NO b. Colfcaon $ Deductible $ Deductible S Deductble S—„_— Deductible EMPLOYER'S NON HIP YES NO COVERAGE •� YES Q NO Q YES r'l NO YES �] NO ERAGE E HIRED CAR COVERAGE L] YES © NO Q YES 0 NO YES NO YES I_M NO —` —�I�r=� ep" �� Agent 1819 --04 4 5/99 Slgnature of Authonzedesenta a Title Agent's Code Number Oate Name and Address of C rtificate Holder Name and Address of Agent Division of Minerals & Geology Dennis Morita State Farm 1313 Sherman St. Room 215 25 N. Harrison St. Denver, CO. 80203 Cortez, CO. 81321 L