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<br />APPENDIX D - Sample Insurance Forms <br /> <br />Sample Additional Insured Endorsement Form <br /> <br />ADDITIONAL INSURED ENDORSEMENT <br /> <br />Insurance Company <br /> <br />This endorsement modifies such insurance as is afforded by the provisions of Policy <br /># relating to the following: <br /> <br />1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California <br />92701; its officers, employees, agents and volunteers are named as additional insureds <br />("additional insureds") with regard to liability and defense of suits arising from the <br />operations and uses performed by or on behalf of the named insured. <br /> <br />2. With respect to claims arising out of the operations and uses performed by <br />or on behalf of the named insured, such insurance as is afforded by this policy is <br />primary and is not additional to or contributing with any other insurance carried by or for <br />the benefit of the additional insureds. <br /> <br />3. This insurance applies separately to each insured against whom claim is <br />made or suit is brought except with respect to the company's limits of liability. The <br />inclusion of any person or organization as an insured shall not affect any right which <br />such person or organization would have as a claimant if not so included. <br /> <br />4. With respect to the additional insureds, this insurance shall not be <br />canceled, or materially reduced in coverage or limits except after thirty (30) days written <br />notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, <br />California 92701. <br /> <br />(Completion of the following, including countersignature, is required to make this <br />endorsement effective.) <br /> <br />Effective <br />Policy # <br />Issued to <br /> <br />, this endorsement form as a part of <br /> <br />. <br /> <br />Named Insured <br /> <br />Countersigned by <br /> <br />. <br />Authorized Representative <br /> <br />Page 32 of 35 <br />