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<br />ENDORSEMENT <br /> <br />~ Golden Eagle <br />\'P Insurance. <br /> <br />IIk:IIIao t1Il..bftJ' .-.. GnIup <br /> <br />Polley Number: CBP9572743 Prior Policy: 9572743 <br />Billing Type: DIRECT BILL <br />Coverage Is Provided In GOLDEN EAGLE INSURANCE CORPORATION <br />Named Insured and Mailing Address: Agent: <br />MASTER LANDSCAPE & MAINTENANCE ELMCO INSURANCE <br />INC 1905 N MAIN ST <br />10171 NORTHAMPTON AVENUE SANTA ANA CA 92706-2728 <br />WESTMINSTER CA 92683 <br /> Agent Code: 4294058 Agent Phone: (714)-973-1436 <br /> <br />POLICY CHANGE ENDORSEMENT <br /> <br />POLICY PERIOD: From: 04102/2010 To: 04/02/2011 at 12:01 AM Standard Time at your mailing address shown above. <br /> <br />DESCRIPTION OF CHANGE <br /> <br />CHANGE EFFECTIVE DATE: 04/02/2010 <br /> <br />PRIMARY AND NON-CONTRIBUTORY WORDING IS <br />GRANTED FOR THE FOLLOWING ADDITIONAL INTEREST <br />PER 22-123 (01/07) ATTACHED: <br /> <br />CITY OF SANTA ANA, Irs OFFICERS, EMPLOYEES, AGENTS <br />AND VOLUNTEERS <br />20 CIVIC CENTER PLAZA <br />SANTA ANA. CA 92701 <br /> <br />JOB: SANTA ANA PARK DISTRICT 4 <br /> <br />Original Annual Premium <br />New Annualized Premium <br /> <br />$ <br />$ <br /> <br />23,513.00 <br />23,618.00 <br /> <br />TOTAL ADDITIONAL PREMIUM <br /> <br />$ <br /> <br />105.00 <br /> <br />Countersigned: By <br /> <br />Authorized Representative <br /> <br />Date <br /> <br />Date Issued: 04106/2010 <br /> <br />17-60 (10/94) <br /> <br />INSURED COPY <br /> <br />04I(J2J2010 <br /> <br />9572743 <br /> <br />NN146931 0704 <br /> <br />PGDtvY)6()[) J01575 <br /> <br />GC3HPPN 00000055 Page 5 <br />