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POLICY CHANGE DOCUMENT <br />POLICY NO. CHANGE # 2 CHANGE EFFECTIVE: 07/23/2011 <br />PHPK751 184 -000 <br />Philadelphia Indemnity Insurance Company PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED <br />MAILING ADDRESS <br />Raymundo Suarez <br />610 S. Townsend St. <br />Santa Ana, CA 92703- <br />POLICY PERIOD: FROM 07/23/2011 TO 07/23/2012 at <br />12:01 A.M. Standard Time at your mailing address shown above. <br />DESCRIPTION _ <br />In consideration of the premium reflected, the policy is amended as indicated below: <br />Amended: Additional Insured City of Santa Ana, its officers, agents, and employees Form CG2026- <br />Additional Insured Designated Person or Organization applies <br />Total Annual <br />Additional /Return Premium <br />Total Annual <br />Add itiona I /Return <br />Tax/Surcharge /Fee <br />COUNTERSIGNED <br />Total Prorate <br />$0.00 Additional /Return Premium <br />$0:00 <br />Total Prorate <br />Additional /Return <br />$0.00 Tax/Surcharge /Fee $0.00 <br />BY <br />(Date) (Authorized Representative) <br />Page 1 of 1 <br />