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C a S1e10/29/09•PACS603738 -03 396707469 "D /B AGENTS COPY <br />MENDED 10 /03/2009 0178469 GREAT AMERICAN A)SLSUq #N& CO <br />Administrative offices 10107 <br />Cincinnati,tOhio 45202 PO I i oy No. PAC 660-37-38 - 03 <br />GR'BATAMEkCN. Tel. 1.513 -369 -soon Effective Date of Change 10/03/2009 <br />BUSINESSPRO POLICY CHANGES <br />MGRS <br />NAMED INSURED THOMAS HOUSE TEMPORARY SHELTER <br />AND ADDRESS: P.O. BOX 2737 <br />GARDEN GR -OVE, CA 92842 <br />THIS ENDORSEMENT AGENT,`$ NAME AND ADDRESS: <br />CHANGES THE POLICY. kU'Nr*I NGTON PACIFIC INS AGY <br />PLEASE READ IT 7901 PROFESSIONAL CIRCLE <br />CAREFULLY. HUNTINGTON BH, CA 92648 0000 <br />Insuranoe is afforded by the Company named below, a Capital Stock Corporation: <br />GREAT AMERICAN ASSURANCE COMPANY <br />POLICY PERIOD: From 10/03/2009 To 10/03/2010 <br />12:01.A.M. Standard Time at the address of the Named Insured <br />IT IS HEREBY UNDERSTOOD AND AGREED THAT THIS POLICY IS AMENDED AS FOLLQWS: <br />0.DDING FORM CG7881: ADDITIONAL INSURED - FUNDING SOURCES (PER ATTACHED). <br />ORSEMENT # 1 <br />ANY AMENDED FORMS ATTACHED TO THIS CHANGE DISPLAY PREMIUMS FOR A FULL <br />POLICY TERM. <br />Forms and Endorsement Activity <br />SDM568 10/04 POLICYHOLDER NOTICE DELETED <br />CG7881 •12/95 'ADDL I- NS- FUNDING•SOURCES ADDED <br />Countersigned �-_ <br />9 Date B Authorized Signature <br />LISP 1r•Cg� At --- .... - - -._. _ ....... <br />_._.__..._.. - - -�- <br />' p,5ststa� <br />IL 70 02 10/07 fpage 1 of 1 ) TOADMSS <br />