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POLICY NUMBER: BAS70BL755 <br />COMMERCIAL AUTO <br />CA 20 48 02 99 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />DESIGNATED INSURED <br />This endorsement modifies insurance provided under the following: <br />BUSINESS AUTO COVERAGE FORM <br />GARAGE COVERAGE FORM <br />MOTOR CARRIER COVERAGE FORM <br />TRUCKERS COVERAGE FORM <br />With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified <br />by this endorsement. <br />This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of <br />the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. <br />This endorsement changes the policy effective on the inception date of the policy unless another date is indicated <br />below. <br />Endorsement effective <br />12/13/2012 <br />Named Insured <br />Countersigned by ,, •/) <br />John E. Kaliski doe John Kaliski Arch. <br />SCHEDULE <br />Name of Person(s) or Organization(s): <br />(Authorized Representative) <br />Person or organization completed to read: City of Santa Ana, its officers, employees, agents, volunteers and representatives <br />(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as <br />applicable to the endorsement.) <br />Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that <br />person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the <br />Coverage Form. <br />CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 <br />