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QPMJDZ!DIBOHF!EPDVNFOU! <br />QPMJDZ!OP/; <br />PHPK2218182 <br />Philadelphia Indemnity Insurance Company116704TDW Risk Management Associates <br />NAMED INSURED <br />Moms Orange County <br />1128 W Santa Ana Blvd <br />MAILING ADDRESS <br /> <br />Santa Ana, CA 92703-3833 <br />POLICY PERIOD:FROMTOat <br />02/24/202102/24/2022 <br />12:01 A.M. Standard Time at your mailing address shown above. <br />CHANGE EFFECTIVE CHANGE # REVISION # <br />06/29/202122 <br /> <br />DESCRIPTION <br />In consideration of the premium reflected, the policy is amended as indicated below: <br />Added: <br />Primary and Non-Contributory form <br />Form PI-GL-005 - Additional Insured - Primary and Non-Contributory Insurance <br />Per attached <br />14874847 <br />Path ID <br />Total AnnualTotal Prorate <br />Additional/Return Premium $Additional/Return Premium $ <br /> 0.00 0.00 <br />NO CHANGENO CHANGE <br />BY <br />COUNTERSIGNED <br />(Authorized Representative) <br />(Date) <br />07/12/2021 <br />____________________ <br />Issue Date <br />Page 1 of 1 <br />Insurance Policy <br /> <br /> <br />