1214 11 PL N-CERT OF INS.pdfPAGE 1
00611 91 15 92A
9800 Fredericksburg Road
San Antonio, Texas 78288 HOMEOWNERS
W % CERTIFICATE OF INSURANCE
USAX UNITED SERVICES AUTOMOBILE ASSOCIATION
1M02221/000001
CITY OF EDMONDS
ENGENEERING DIVISION
121 5TH AVE N
EDMONDS WA 98020-3145
"TIED
SE-P 2 6 2016
09/15/16
Policy Number: uuo 1 1 u 1 is UZ/A Loan imumDer'.
Policy Form: RO 9 Effective Date: Expiration Date: 11/28/17
ADDITIONAL INTEREST interest: CITY/ MUNICIPALITY
-N[a-m-e-------GIT7 OF EDMUNDS
Address:
ENGENEERING DIVISION
121 5TH AVE N
EDMONDS WA 98020-3145
PROPERTY INFORMATION
on: 1214 11TH PL N
EDMONDS, SNOHOMISH, WA 98020-2548
Legal Description:
COVERAGE INFORMATION* Coverage applies only if a limit is shown.
Coverage Limit
------Coverage Limit
Dwelling:
Personal Liability: 30U-,UO-
Other Structures:
Medical Payments: $5,000
Personal Property:
Deductible:
Annual Premium:
rmtrtnntu muicuim)i rLIAIV
See back of form for an important disclosure.
* Copy of contract available upon request.
DWGCOI 08-12
SCANNED
S E P 2 r) ?o'jfi
126240-031203
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