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*POLICY NUMBER: <br /> <br />UNI-CGL-03-01--018 (1-14601-00-03) <br /> <br />*INSURED COMPANY NAME: American Unity Group <br /> <br />ENDORSEMENT <br /> <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> <br /> ADDITIONAL INSURED - DESIGNATED PERSON or <br /> ORGANIZATION <br /> <br /> This endorsement modifies insurance provided under the following: <br /> <br /> COMMERCIAL GENERAL LIABILITY COVERAGE PART <br /> <br /> SCHEDULE <br /> <br />Name of Person or Organization: St. Joseph Health System <br /> <br /> City of Santa Aha and its Officers, Agents, Employees and <br /> Volunteers are named as additional insured as respects their <br /> interest in connection with the named insured. <br /> <br /> (If no entry appears above, information required to complete this endorsement will be <br /> shown in the Declarations as applicable to this endorsement.) <br /> <br /> WHO IS AN INSURED (Section II) is amended to include as an insured the person or <br /> organization shown in the Schedule, but only with respect to liability arising out of your <br /> operations or premises owned by or rented to you. <br /> <br /> IT IS AGREED THAT ANY INSURANCE MAINTAINED BY THE CITY OF <br /> SANTA ANA SHALL APPLY IN EXCESS OF, AND NOT CONTRIBUTE WITH, <br /> INSURANCE PROVIDED BY THIS POLICY. <br /> <br /> Agent's S ignatu re: ~,~~/ ~'--~~ <br /> <br />CG 2010 11 85 <br /> <br />(21g)C SAMPLE- Additional I nsur,:d with Primary/Non-Contributing Language Added <br /> <br /> APPROVED AS TO <br /> <br /> La~ra SI'reedy <br /> Deputy City Attorney <br /> <br /> <br />