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POLICY NUMBER: 6BRPG0000005142000 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 />6BRPG0000005142000 <br />09/19/12 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Sandra p ramirez <br />K &K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Form SRPG8018 is added to the policy in regards to primary coverage. <br />Additional Insured: <br />City of Santa Ana, its officers, employees, agents, representatives &volunteers <br />20 Civic Center Plaza <br />Santa Ana, CA 92701 <br />Cert Policy #3309 <br />The above amendments result in a change of premium as follows: <br />No Chan a To be Adjusted at Audit <br />Additional Premium <br />' ""��I /u^�!�'r <br />Authorized Representative Signature <br />IL 12 01 11 85 Copyright, Insurance Services OfFce, Inc., 1983 <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />�pROVE� <br />AS 1 <br />a of. ? <br />3(7 <br />