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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHPK430634 <br />Philadelphia Indemnity Insurance Company Unassigned (SB) <br />NAMED INSURED Raymundo Suarez <br />MAILING ADDRESS 610 S Townsend Street <br />Santa Ana, CA, 92703 <br />POLICY PERIOD: FROM 06/15/2009 TO 06/15/2010 at <br />12:01 A.M. Standard Time at your mailing address shown above <br />CHANGE EFFECTIVE 07/28/2009 CHANGE # 1 <br />DESCRIPTION <br />Add Additional Insured: CITY OF SANTA ANA 20 CIVIC CENTER PLAZA SANTA ANA CA 92701 <br />Path ID: 3831263 <br />Total Annual <br />Additional /Return Premium <br />COUNTERSIGNED <br />$0.00 Total Prorate <br />Additional /Return Premium $172.00 <br />(Date) <br />BY <br />Page 1 of 1 <br />(Authorized Representative) <br />