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POLICY NO: <br />PHPK661902-002 <br />POLICY CHANGE DOCUMENT <br />CHANGE # 3 CHANGE EFFECTIVE: 12/17/2012 <br />Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED: Choc V Le <br />MAILING ADDRESS 4 Fabriano <br />Irvine, CA 92620-2576 <br />POLICY PERIOD: FROM 12/17/2012 TO 12/17/2013 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 />Added: Additional Insured City of Santa Ana, its officers, agents and employees 20 Civic Center Plaza <br />M-25 Santa Ana CA 92701 Form CG2026-Additlonal Insured Designated Person or Organization <br />applies <br />Total Annual Total Prorate <br />Additional/Return Premium $0.00 Additional/Return Premium $0.00 <br />Total Annual Total Prorate <br />Additional/Return Additional/Return <br />Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 <br />�pRO,vE.D AS <br />TO FOS <br />Page 1 of 1 S, ORCK <br />t.1S� C+tY Attorney <br />A55�sta �t <br />