1214 11TH PL N-CERT OF INS.pdfPAGE 1
9800 Fredericksburg Road o061 1 91 15 92A
V% San Antonio, Texas 78288 HOMEOWNERS
CERTIFICATE OF INSURANCE
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UNITED SERVICES AUTOMOBILE ASSOCIATION
02221.42T6F.JSS1504165926.01.01.1109 10/04/17
CITY OF EDMONDS
ENGENEERING DIVISION
121 5TH AVE N
EDMONDS WA 98020-3145
POLICY INFORMATION
AMENDED EFFECTIVE 11/28/17
Named Insured: JUDITH G CHERMAK AND HOWARD L CHERMAK
Policy Number: 00611 91 15 92A Loan Number:
Policy Form: HO 9 Effective Date: 11 28 17 Expiration Cate: 11i 28 18
ADDITIONAL INTEREST
Name: CITY OF EDMON
ENGENEERING DIVISION
121 5TH AVE N
EDMONDS WA 98020-3145
Location:
Legal Description:
Interest: CITY/MUNICIPALITY
EDMONDS, SNOHOMISH, WA 98020-2548
COVERAGE INFORMATION* Coverage applies only if a limit is shown.
Coverage Limit Coverage Limit
Dwelling: Personal Liability: $300,000
Other Structures: Medical Payments: $ , 000
Personal Property:
Deductible: Annual Premium:
See back of form for an important disclosure.
* Copy of contract available upon request. 126240-0312_03
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