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POLICY NUMBER: 6BRPG0000004934600 INTERLINE <br />IL 12 01 11 85 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY_ <br />POLICY CHANGES <br />Policy Charge <br />Number 3 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPG0000004934600 <br />04/21111 <br />Nationwide Mutual insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Maria R. Vigil <br />K&K Insurance Group, Inc. <br />I DBA: Ria Vigil Group Fit <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL_ LIABILITY COVERAGE <br />CHANGES <br />j Form Number_ CG2011 'Additional Insured — Managers or Lessors of Premises- <br />; Add Form F__j Delete Form �_ Amend Form To include Additional Insured Below: <br />City of Santa Ana, its officers, agents and employees <br />Parks. Recreation and Community Services Agency <br />Attn: Silvia Cuevas <br />26 Civic. Center Plaza <br />Santa Ana, CA 92701 <br />i <br />Raf: CP# 552 <br />The above amendments result in a change in the premium as follows: <br />X <br />NO CHANGES <br />TG 13E ADJUSTED <br />ADDITIONAL PR-�MIUM RETURN PREMIUM <br />i 1 <br />i <br />AT AUDIT <br />Authorized Representative Signature <br />IL 12 01 11 85 Copyright; Insurance Services Office. Inc_ 1983 Page 1 of 1 <br />Copyright, ISO Commercial Risk Services. Inc-, 1983 <br />