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ANDERSON & MURISON, <br />800 W.COLORADO BLVD <br />LOS ANGELES. CA 90041 <br />Producer Number: <br />037838 <br />Producer Name: <br />HUNTINGTON PACIFIC INS. AGENCY <br />Address: <br />18672 FLORIDA ST.,STE. 302D <br />Policy Expiration Date: <br />HUNTINGTON BEACH, CA 92648 <br />General Change Endorsement <br />Provider Number: SO <br />Provider Name: SCOTTSDALE INSURANCE COMPANY <br />Address: P O BOX 4110 <br />SCOTTSDALE, AZ 85261 <br />Insured Number: 56231 <br />Policy Number: CLS109909"1 <br />Insured Name: THOMAS HOUSE TEMPORARY SHELTER <br />Policy Inception Date: <br />07/09 /2005 <br />Insured Address: P.O. BOX 2737 <br />Policy Expiration Date: <br />07/09 /2006 <br />GARDEN GROVE, CA 92842 <br />Endorsement Number: <br />4 <br />Endorsement Effective Date: <br />0710942005 <br />Endorsement Expiration Date: <br />07109/2006 <br />Processed on: <br />10/180005 <br />In accordance with the terms and conditions of the above mentioned policy, the policy is hereby amended as follows: <br />Transaction Reason: <br />AMEND ADDITIONAL INSURED FORM CG2011 TO CG2026 FOR CITY OF SANTA ANA <br />Extended Reason: <br />THE FOLLOWING ADDITIONAL INSURED ENDORSEMENT FOR THE CITY OF SANTA ANA IS HEREBY AMENDED <br />TO FORM CG2026, DESIGNATED PERSON OR ORGANIZATION <br />THE UT8-3g FORM (PRIMARY / NON - CONTRIBUTORY WORDING) FOR THE CITY OF SANTA ANA IS AMENED <br />TO REFLECT THE CG2026 FORM. <br />PLEASE NOTE, THE CG2011 A/I FORM (AND CORRESPONDING UTS -3g FORM) FOR THE CITY OF SANTA <br />ANA, HAS BEEN DELETED FROM THE POLICY EFF JULY 9, 2005 <br />GaneM*4b, He Oer Renalds <br />eanarata<en: IWIGMM 1007 AM <br />enatwer: Heamer Remolds <br />PPS- NENDTI <br />PPKOVLi 0 AS TO FORM <br />�lt <br />.:;!a Stitt Sheedy <br />C;i!v Attcroev <br />Page 1 of 1 <br />