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POLICY CHANGE DOCUMENT <br />POLICY NO.: PHPK930398 <br />Philadelphia Indemnity Insurance Companyl 18922 1. Smith Lanier & Co. <br />NAMED INSURED Henry Ramirez DBA Bay Area Driving <br />Driving School Safety Drivers Ed, LLC <br />MAILING ADDRESS 1070 A St <br />Hayward, CA 94541-4106 <br />POLICY PERIOD: FROM 11/01/2012 TO 11/01/2013 at <br />12:01 A.M. Standard Time at your mailing address shown above. <br />CHANGE EFFECTIVE 07/26/2013 CHANGE # 5 <br />DESCRIPTION <br />In consideration of the premium reflected, the policy is amended as indicated below: <br />Added: <br />Additional Insured <br />The City of Santa Ana, its officers, employees, agents and volunteers <br />20 Civic Center Plaza <br />Santa Ana, California 92701 <br />PI-MANU-1 - Additional Insured - Primary and Non -Contributory Insurance <br />Per attached schedule and form <br />"TO v0s," <br />1S °c. �10RCK <br />pssIs l City Attorney <br />Path ID 7282881 <br />Total Annual Total Prorate <br />Addltional/Return Premium $ 0.00 Additional/Return Premium $ 0.00 <br />NO CHANGE NO CHANGE <br />COUNTERSIGNED BY <br />(Date) (Authorized Representative) <br />Insurance Policy Page 1 of 1 <br />