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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 Change <br />Numher 7 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPG0000004934600 <br />05/19/11 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Maria L Madrigal <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Form Number: CG2011 "Additional Insured — Managers or Lessors of Premises" <br />Add Form Delete Form XD Amend Form To Include Additional Insured Below: <br />City of Santa Ana, its officers, employees, agents and representatives <br />20 Civic Center Plaza <br />Santa Ana, CA 92701 <br />Ref: CP# 831 <br />The above amendments result in a change in the premium as follows: <br />NO CHANGES <br />TO BE ADJUSTED <br />AT AUDIT <br />ADDITIONAL PREMIUM <br />RETURN PREMIUM <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 />