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®Allstate <br />SPECIAL FORM CUSTOMIZER POLICY NO. 050 828050 <br />SUPPLEMENTAL DECLARATIONS <br />4. ADDITIONAL INTERESTS <br />This policy covers the interests of any of the following when named below. The Mortagee, under Coverage A - <br />Part One, the Loss Payee under Coverage A - Part Two, the Additional Insured under Coverage B - Part One, and <br />the Vendor, under Coverage B - Part One. <br />LOC. <br />No. <br />Bldg. <br />NO. <br />AddMonal <br />Interest <br />Name & Address <br />001 <br />001 <br />ADDITIONAL INSURED <br />YOUNG REMBRANDTS <br />23 NORTH UNION ST <br />ELGIN, IL 60123-5334 <br />001 <br />001 <br />ADDITIONAL INSURED <br />PLACENTIA YORBA LINDA UNIFIED SCHOOL DISTRICT <br />1301 E ORANGETHORPE AVE <br />PLACENTIA, CA 92870 <br />001 <br />001 <br />ADDITIONAL INSURED <br />THE CA CONGRESS OF PARENTS, TEACHERS, <br />STUDENTS, INC <br />300 E 15TH ST <br />NEWPORT BEACH, CA 92563 <br />001 <br />001 <br />ADDITIONAL INSURED <br />CITY OF COSTA MESA <br />77 FAIR DRIVE <br />COSTA MESA, CA 92626-6520 <br />001 <br />001 <br />ADDITIONAL INSURED <br />CITY OF YORBA LINDA <br />' <br />4501 CASA LOMA AVE <br />YORBA LINDA, CA 92886-3315 <br />001 <br />001 <br />ADDITIONAL INSURED <br />CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, <br />VOLUNTEERS AND REPRESENTATIVES <br />20 CIVIC CENTER PLAZA <br />SANTA ANA, CA 92701-4058 <br />001 <br />001 <br />ADDITIONAL INSURED <br />CITY OF ORNAGE ITS DIRECTORS, OFFICERS, <br />AGENTS AND EMPLOYEES <br />300 E CHAPMAN AVE <br />ORANGE, CA 92866 <br />BU5575.3 <br />EJ11JR f <br />Page 1 <br />