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POLICY CHANGE DOCUMENT <br />POLI_C NO: CHARGE -1 1 -CHANGE -EFFECTIVE:: 02/0612814 <br />PHPK977541-001 <br />Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED: Martin Torres <br />MAILING ADDRESS 12692 Ranchero Way <br />Garden Grove, CA 92843 - <br />POLICY PERIOD: FROM 02/06/2014 TO 02/06/2015 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 />Amend Additional Insured, City of Santa Ana, to include special wording and 30 day cancel notice. <br />Form CG2026-Additional Insured Designated Person or Organization 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 />Page 1 of 1 <br />- �- „City i+ttornPv <br />