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ENDORSEMENT <br />Policy Number: CBP9572743 Prior Policy: 9572743 <br />Billing Type: DIRECT BILL <br />Coverage Is Provided In GOLDEN EAGLE INSURANCE CORPORATION <br />Named insured and Mailing Address: Agent: <br />MASTER LANDSCAPE 8, MAINTENANCE ELMCO INSURANCE <br />INC 1905 N MAIN ST <br />10171 NORTHAMPTON AVENUE SANTA ANA CA 92706-2728 <br />WESTMINSTER CA 92683 <br />Golden Eagle <br />Insurance. <br />U=W.f LftM NVCW Qw* <br />Agent Code: 4294058 Agent Phone: (714) -973 -1436 <br />F <br />POLICY UHANUt tNUUKa MV1"1Y 1 <br />POLICY PERIOD: From: 0410212009 To: 04/0212010 at 12.01 AM Standard T t yo mailing address shown above. <br />DESCRIPTION OF CHANGE HA E FECTIVE DATE: 0711012009 <br />THE FOLLOWING PRIMARY NON CONTRIBUTORY WOR IN N <br />APPLIES PER THE ATTACHED 17 -59 AND 22.123 AS FOLL W <br />CITY OF SANTA ANA •�': `' ` {:\ <br />P.O. BOX 1988 \v1 <br />SANTA ANA, CA 92702 <br />JOB: LAWN MAINTENANt'AR IN ISTRICT4 SANTA <br />ANA, <br />DURATION: ANNUAL <br />Original Annual Premium $ 31,141.00 <br />Now Annualized Premium $ 31,246.00 TOTAL ADDITIONAL PREMIUM $ 77.00 <br />Countersigned: By Date <br />Aulharfzed Representative <br />Date Issued: 0711512009 <br />17.64 (10194) <br />INSURED COPY <br />P <br />041=009 9572743 NEUSXGIP1607 ODMO60D !10981 OCAFPFN 00000111 Page 5 <br />