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R <br />F� <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />POLICY CHANGE <br />This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated <br />below: <br />Policy Number: 72 SBA IA4429 DX <br />rn <br />Ln <br />COPY <br />Named Insured and Mailing Address; PULMONARY CONSULTANTS <br />SEE FORM IH1200 <br />1310 W. STEWART DR <br />ORANGE CA 92868 <br />Policy Change Effective Date: 08/24/09 Effective hour is the same as stated in the <br />Declarations Page of the Policy. <br />Policy Change Number: 003 <br />Agent Name: WOOD GUTMANN & BOGART INS BKR /PHS <br />Code: 181021 <br />POLICY CHANGES: <br />HARTFORD CASUALTY INSURANCE COMPANY <br />ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING <br />STATEMENT. <br />THIS IS NOT A BILL. <br />NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE <br />BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED <br />ADDITIONAL INSURED(S) ARE ADDED <br />THE FOLLOWING ARE ADDITIONAL INSURED FOR BUSINESS LIABILITY COVERAGE IN <br />THIS POLICY. <br />LOCATION 001 BUILDING 001 <br />PERSON /ORGANIZATION: SEE FORM IH 12 00 <br />FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: <br />SS 14 23 10 03 <br />PRO RATA FACTOR: 1.000 <br />THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. <br />Form SS 12 11 04 05 T Page ool (CONTINUED ON NEXT PAGE) <br />Process Date: 08/25/09 Policy Effective Date: 08/24/09 <br />Policy Expiration Date: 05/01/10 <br />