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POLICY NO: <br />PHPK661902-003 <br />POLICY CHANGE DOCUMENT <br />CHANGE # 1 CHANGE EFFECTIVE: 12/17/2013 <br />Philadelphia Indemnity Insurance Company 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 12/17/2013 TO 12/17/2014 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 />Amended Additional Insured to read: City of Santa Ana, its officers, employees, agents, representatives <br />& volunteers <br />Total Annual Total Prorate <br />Additional/Return Premium $0.00 Additional/Return Premium $0.00 <br />Total Annual Total Prorate <br />Addltional/Return Additional/Return <br />Tax/Surcharge/Fee $0.00 Tax/Surcharge/Pee $0.00 <br />Page 1 of 1 <br />