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POLICY CHANGE DOCUMENT <br />POLICY NO: CHANGE # 2 CHANGE EFFECTIVE: 09/27/2021 <br />PHPK2330395-000 <br />Philadelphia Indemnity Insurance Company PRODUCER: Maguire Insurance Agency, Inc. FWI <br />NAMED INSURED: Maritsa Secundo <br />MAILING ADDRESS 7143 Fulton Way <br />Stanton, CA 90680- <br />POLICY PERIOD: FROM 09/2712021 TO 09/27/2022 at <br />12:01 A.M. Standard Time at your mailing address shown above. <br />DESCRIPTION: <br />In consideration of the premium reflected, the policy is amended as indicated below: <br />Added 1 Additional Insured. <br />Total Annual Total Prorate <br />Additional/Return Premium $0.00 Additional/Return Premium $0.00 <br />Total Annual Total Prorate <br />Additional/Return Additional/Return <br />Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0,00 <br />A4&APPR( WPr <br />t flCUIEVh'�SMPpIMD4Y: <br />P , lir � oo,G 7aec+ao,e a <br />Page 1 of 1 mnau�a•,a n .da�o <br />