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17?/� <br />F <br />2� <br />POLICY NUMBER: 6BRPG0000005342300 INTERLINE <br />IL12011185 <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 />6BRPG0000005342300 <br />05/31/13 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Carmen M. Whitmer <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Form SRPG8016 and SRPG 8018 are added to the policy in regards to: <br />The City of Santa Ana, officers, employees, agents and representative <br />20 Civic Center Plaza <br />Santa Ana, California 92701 <br />CP# 4613 <br />Effective: 9/13/13 — 5/31 /15 <br />The above amendments result in a change of premium as follows: <br />FTNo Change To be Adjusted at Audit Additional Premium Return Premium <br />Ai-t ! "�-r/t <br />Authorized Representative Signature <br />�ApyA0V.ZD To <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 />