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POLICY NUMBER: 6BRPGO000005515500 <br />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 1 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPGO000005515500 <br />02/13/14 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Maria L Madrigal <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Forms CG2011, SRPG8016 and SRPG8018 are added to the policy. <br />Additional Insured: <br />City of Santa Ana, its officers, agents, and employees <br />1825 W Civic Center <br />Santa Ana, CA 92704 <br />The Policy Changes Effective Date is changed to read: 02/20/14 <br />RE: Cert Policy #1002 <br />The above amendments result in a change of premium as follows: <br />F-xl No Change 71 To be Adjusted at Audit 1:1 Additional Premium 17 Return Premium <br />Authorized Representative Signature <br />IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />