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POLICY NO: <br />PHPK1362709-000 <br />POLICY CHANGE DOCUMENT <br />CHANGE # 4 CHANGE EFFECTIVE: 12/07/2015 <br />Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED: Illary Archilla <br />MAILING ADDRESS 1 Dover <br />Trabuco Canyon, CA 92679- <br />POLICY PERIOD: FROM 07/06/2015 TO 07/06/2016 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 />30 day cancellation. <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 />Reviewed by <br />Carmen Acosta <br />Page 1 of 1 <br />