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POLICY NO: <br />PHPK803569 -000 <br />POLICY CHANGE DOCUMENT <br />CHANGE # 6 CHANGE EFFECTIVE: 02/09/2012 <br />Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED: Chihiro Sano <br />MAILING ADDRESS 106 Yorktown Ln <br />Costa Mesa, CA 92626- <br />POLICY PERIOD: FROM 12/08/2011 TO 12/08/2012 at <br />12:01 A.M. Standard Time at your mailing address shown above. <br />DESCRIPTION: <br />In consideration of the premium reflected, the policy is amended as indicated below: <br />Amended: Additional Insured 30 day cancellation notice Form CG2026- Additional Insured Designated <br />Person or Organization applies <br />Total Annual Total Prorate <br />Additional /Return Premium $0.00 Additional /Return Premium $0.00 <br />Total Annual <br />Additional /Return <br />Tax/Surcharge /Fee <br />Total Prorate <br />Additional /Return <br />$0.00 Tax/Surcharge /Fee <br />Page 1 of 1 <br />$0.00 <br />