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Policy Number: CP 2151225 <br />UNITED STATES LIABILITY INSURANCE GROUP <br />'WAYNE, PENNSYLVANIA <br />This Endoserwrit modiNes Insurance provided under the foiloMrig: <br />LIQUOR LIABILITY COVERAGE FORM <br />ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION <br />SCHEDULE <br />Name of Person or Organization: Effective Date <br />The City of Santa Ana, Its offlcm. employees, agents and volunteers O 24=0 <br />20 Civic Center <br />Santa Ana, CA 927011 <br />(If no entry appears above, Information required to complete this endorsement will be shown in <br />the Declarations as applicable to this endorsement) <br />WHO IS AN INSURED (Section ll) is amended to indude as an Insured the person or <br />organization shown in the Schedule as an Insured but only with respect to IiabiGty arising out of <br />your operations or.premises owned by or rented to you. <br />All other terms and conditions of this Policy remain unchanged. This endorsement is a part of your <br />Policy and takes effect cn the effective date ofyour Policy unless another effective date is shown. <br />L-580 (03/03) Page 1 Of 1 <br />