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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHPK897643 <br />Philadelphia Indemnity Insurance Company 26548 The Allen ]. Flood Companies, Inc. <br />NAMED INSURED The California Youth Spirit 8c <br />Twirling Corps. <br />MAILING ADDRESS 22755 Mesa Springs Way <br />Moreno Valley, CA 92557 -2628 <br />POLICY PERIOD: FROM 08/01/2012 TO 08/01/2013 at <br />12:01 A.M. Standard Time at your mailing address shown above. <br />CHANGE EFFECTIVE 08/31/2012 CHANGE # 1 <br />DESCRIPTION <br />In consideration of the premium reflected, the policy is amended as indicated below: <br />Added <br />Form CG2015 Addl Insured- Vendors applies with respect to: <br />Additional Insured <br />City of Santa Ana <br />It's officers, agents and employees <br />20 Civic Center Plz <br />Santa Ana, CA 92701 -4058 <br />With respects to vendor contract. <br />Per attached form and schedule <br />Deleted <br />Form CG2026 Addl insured- Designated Person or Organization: <br />Additional Insured <br />City of Santa Ana <br />20 Civic Center Plz <br />Path ID 6462107 <br />Total Annual Total Prorate <br />Additional /Return Premium $ 0.00 Additional /Return Premium $ 0.00 <br />NO CHANGE NO CHANGE <br />COUNTERSIGNED BY <br />(Date) (Authorized Represe£DvRS TO � ®RM <br />APPRO <br />SA E. STORCK <br />Insurance Policy ,�o,R,�orney <br />Assist <br />�� <br />