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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHPK884646 <br />Philadelphia Indemnity Insurance Companyl 109274 A & J Insurance Agency Inc. <br />NAMEDINSURED Eddie Napper dba: Youth Business Network <br />Project <br />MAILING ADDRESS 650 S Grand Ave Ste 105 <br />Santa Ana, CA 92705-4157 <br />POLICY PERIOD: FROM 06/22/2012 TO 06/22/201.3 at <br />12;01 A.M. Standard Time at your mailing address shown above. <br />CHANGE EFf ECTIVE 07/01/2012 CHANGE # I <br />DESCRIPTION <br />In consideration of the premium reflected, the policy is amended as Indicated below: <br />Added: <br />Additional Insured <br />City of Santa Ana <br />20 Civic Center Plz <br />Santa Ana, CA 92701 <br />With respect to Contract Requirement - Funding Source <br />Form CG2026 - Add] Insured -Designated Person or Organization <br />Per attached schedule <br />Path ID 6427778 <br />Total Annual <br />Addltional/Roturn Premium <br />50,00 <br />ADDITIONAL <br />COUNTERSIGNED BY <br />(Date) <br />T® Foyx <br />Assistant City Attorne'7 <br />Total Prorate <br />AdditlonaUfZaturn Premium $ 50.00 <br />ADDITIONAL <br />Insurance Policy <br />(Authorized Representative) <br />Page i of 1 <br />