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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHPK661902 <br />Philadelphia Indemnity Insurance Company Unassigned (SB) <br />NAMED INSURED Choc V Le <br />MAILING ADDRESS <br />POLICY PERIOD <br />CHANGE EFFECTIVE <br />4 Fabriano <br />Irvine, CA, 92620 <br />FROM 12/17/2010 TO 12/17/2011 <br />12:01 A.M. Standard Time at your mailing address shown above <br />12/17/2010 CHANGE # 3 <br />DESCRIPTION <br />Adding Additional Insured: City of Santa Ana 20 Civic Center Plaza M-25 Santa Ana, CA 92701 <br />Path ID: 4972571 <br />Total Annual <br />Additional/Return Premium <br />COUNTERSIGNED <br />$0.00 <br />(Date) <br />Total Prorate $0.00 <br />Additional/Return Premium <br />Page 1 of 1 <br />at <br />(Authorized Representative) <br />