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POLICY CHANGE DOCUMENT <br /> POLICY NO.: PHPK2716952-000 <br /> Philadelphia Indemnity Insurance Companyl 17833 United Agencies Inc. <br /> NAMED INSURED Lutheran Social Services of Southern CA <br /> MAILING ADDRESS 999 W Town and Country Rd Ste 100 <br /> Orange, CA 92868-4713 <br /> POLICY PERIOD: FROM 07/01/2025 TO 08/31/2026 at <br /> 12:01 A.M. Standard Time at your mailing address shown above. <br /> CHANGE EFFECTIVE 07/01/2025 CHANGE# 5 REVISION # 5 <br /> DESCRIPTION <br /> In consideration of the premium reflected, the policy is amended as indicated below: <br /> Amended: <br /> Additional Insured <br /> City of Santa Ana Community Development Agency to read: <br /> City of Santa Ana Community Development Agency; City of Santa Ana, its City <br /> Council, officers, officials, employees agents and volunteers <br /> Per attached <br /> Path ID 18722037 <br /> Total Annual Total Prorate <br /> Additional/Return Premium$ 0.00 Additional/Return Premium$ 0.00 <br /> NO CHANGE NO CHANGE <br /> COUNTERSIGNED BY <br /> (Date) (Authorized Representative) <br /> 08/29/2025 <br /> Issue Date Agency Copy Page 1 of 1 <br />