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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHPK445957 <br />Philadelphia Indemnity Insurance Company Unassigned (SB) <br />NAMED INSURED Body by Bootcamp <br />MAILING ADDRESS <br />POLICY PERIOD: <br />CHANGE EFFECTIVE <br />9912 Colony Grove Lane <br />Villa Park, CA, 92861 <br />FROM 09/01/2009 TO 09/01/2010 at <br />'12:0'1 A.M. Standard Time at your mailing address shown above <br />09/01/2009 CHANGE # 1 <br />DESCRIPTION <br />to add additional insured certificates for: City of Santa Ana Parks and Services Agency RSCCD Santiago Canyon <br />College and Orange Unified School District Attn: Colleen Derham <br />Path ID: 4263263 <br />Total Term <br />Additional /Return Premium <br />COUNTERSIGNED <br />$0.00 <br />(Date) <br />APPROVE O FORM <br />�p FLETCHER <br />ATTORNEY <br />Total Prorate $0.00 <br />Additional /Return Premium <br />BY <br />Page 1 of 1 <br />(Authorized Representative) <br />