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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHpK65�522 <br />Phlladalphla Indemnity Insurance Company 21526 Lake Insurance Agency <br />NAMED INSURED Orange County Chlidren's Therapeutic <br />Art Center, [nc <br />MAILINGADORESS 2215 N Broadway <br />Santa Ana, CA 92706 -2663 <br />POLICY PERIOD: FROM 12/21/2010 70 12/21/2011 at <br />12:01 A.M. Standard Tlme at your mailing address ahowmabovo. <br />CHANGE EFFECTIVE 06/13/2011 CHANGE # 1 <br />DESCRIPTION <br />In consideration of the prernlum reflected, lltie policy Is amended as Indicated below: <br />ADDED: <br />Addltlonal Insured: <br />The City of Santa Ana, Its Officers, <br />Employees, Agents and Volunteers <br />20 Clvlc Center Plaza <br />Santa Ana CA 92702 <br />As respects the pr•Imary 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 />AddtUonal/Relurn Premium $ <br />COUNTERSIGNED <br />0.00 <br />NO CHANGE <br />(Dafe) <br />U'1'1 <br />Total Prorate <br />Addltlonal /Return Premium $ 0.00 <br />NO CHANGE <br />14.1P7P:Eic"UV€fl 1�i� `r© �'OR1VI <br />LI�STORCK -Insurance Policy <br />Assistant City Attorney <br />(�� <br />(Authorized Representative) <br />Page 1 of i <br />