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2912-07-0516:57 7145581980 <br />7145581980 >> 18668561851 <br />P 3/4 <br />POLICY CHANGE DOCUMENT <br />POLICY NO: CHANGE # 1 CHANGE EFFECTIVE: 01/24/2012 <br />PHPK523557-002 <br />Philadelphia Indemnity insurance Company PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED: Martin Torres <br />MAILING ADDRESS 12692 Ranchero Way <br />Garden Grave, CA 92843-3027 <br />POLICY PERIOD'. FROM 01/24/2012 TO 01/24/2013 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 />Effective 06/1812012. Added CO2404 Waiver of Transfer of Rights of Recovery Against Others To Us <br />With respects to Additional insured; The City of Santa Ana, officers, employees, agents and <br />representatives, 20 Civic Center Piero, Santa Ana, CA 92701 <br />Total Annual Total Prorate <br />AddWneVRetuen Premium $100.00 AdditionaMetum Premium $100-00 <br />Total Annual Total Prorate <br />AdditionallReturn AddltlonaVRetum <br />Tex/SUf0ergetFee $0.00 Tex/SurchargaTee 30.00 <br />rA <br />Page 1 of 1 <br />