POULSBO MUNICIPAL COURT Kitsap County, Washington 200 NE Moe St, Poulsbo, WA 98370 Phone # 360-779-9846 Fax # 360-779-1584 CITY OF POULSBO, Case # Plaintiff, vs. NOTICE OF INSURANCE COVERAGE FOR DEFERRED PROSECUTION ______________________________________, Defendant. This notice is to advise both the court and the plaintiff of the nature and extent of insurance coverage held by the above-named defendant who is petitioning for Deferred Prosecution in this court. This coverage is to show compliance with the requirements of RCW 10.05.140 and is included by reference, RCW 46.29.490. NAME OF INSURED: __________________________________________________________ ADDRESS OF INSURED: _______________________________________________________ COVERAGE: Bodily injury/death to one person: $____________________________ Bodily injury/death to two or more persons: $____________________________ Injury to/destruction of property of others: $____________________________ PREMIUM: ___________________________________________________________________ POLICY PERIOD: _____________________________________________________________ LIMITS OF LIABILITY: __________________________________________________________ Attached is an agreement or endorsement that insurance is provided under the policy in accordance with the coverage defined in this chapter as respects bodily injury and death or property damage, or both, and is subject to all the provisions of this chapter. THE ABOVE INFORMATION IS GIVEN AS TRUE AND ACCURATE. DATED this _____ day of ____________________ 20_______. PRESENTED BY: ______________________________________ Attorney for Petitioner Notice of Insurance Coverage 4/8/08 _____________________________ Defendant Attachment A American LegalNet, Inc. www.FormsWorkFlow.com