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POLICY CHANGE DOCUMENT <br />POLICY NO: <br />P H P K2324258-001 <br />CHANGE # 1 CHANGE EFFECTIVE: 09/09/2022 <br />Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. FWI <br />NAMED INSURED: mtorres alvarez <br />MAILING ADDRESS 2222 S Mohawk Ave <br />Santa Ana, CA 92704- <br />POLICY PERIOD: FROM 09/09/2022 TO 09/09/2023 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 Additional Insured with WOS PNC SAM Limits:City of Santa Ana, Parks, Recreation and Community <br />Services20 Civic Center Plaza, Santa Ana, CA 92701 <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 />�Ao�nH Risk <br />Page 1 Of 1 z'� REVIEWED&APPROVED Or <br />�— Risk Management Analyst <br />