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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHPK651522 <br />Philadelphia Indemnity Insurance Companyl 21526 Lake Insurance. Agency <br />NAMED INSURED Orange County Children's Therapeutic <br />Art Center, Inc <br />MAILING ADDRESS 2215 N Broadway <br />Santa Ana, CA 92706-2663 <br />POLICY PERIOD: FROM 12/21/2010 TO 12/21/2011 at <br />12;01 A.M. Standard Time at your mailing address shown above. <br />CHANGE EFFECTIVE 06/13/2011 CHANGE # 1 <br />DESCRIPTION <br />In consideration of the premium reflected, the policy Is amended as Indicated below: <br />ADDED: <br />Additional Insured: <br />The City of Santa Ana, Its Officers, <br />Employees, Agents and Volunteers <br />20 Civic Center Plaza <br />Santa Ana CA 92702 <br />As respects the primary Insured's therapeutic art services under contract <br />with the city <br />Form: CG2026 Designated Person or Orgalzatlon <br />Per attached schedule <br />Path ID 5432771 <br />Total Annual <br />Additional/Return Premium $ 0.00 <br />NO CHANGE <br />COUNTERSIGNED <br />(Date) <br />14�P VED AS TO FORM <br />LISA E. STORCK <br />Assistant City Attorney <br />BY <br />Total Prorate <br />Additional/Return Premium $ 0.00 <br />NO CHANGE <br />(Authorized Representative) <br />Insurance Policy Page 1 of 1 . <br />