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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 />Number 2 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPG0000004934600 <br />11/02/11 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Janet Farias Coca -Garcia <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Form SRPG8016 is added to the policy in regards to a 30 day cancellation notice. <br />Additional Insured: <br />City of Santa Ana, its officers, agents and employees <br />Parks, Recreation and Community Services Agency <br />Attn: Carmen Acosta <br />1825 W. Civic Center <br />Santa Ana, CA 92701 <br />Cert Policy #4270 <br />The above amendments result in a change of premium as follows: <br />EKINo Change To be Adjusted at Audit Additional Premium Return Premium <br />-X� <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 />