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POLICY NO: <br />PHPK1473005-000 <br />POLICY CHANGE DOCUMENT <br />CHANGE#5 CHANGE EFFECTIVE: 04/11/2016 <br />Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED� Connie McGuire <br />MAILING ADDRESS 53AEWashington Ave <br />Orange, CA928GG- <br />POL[CYPERIOD: FROM 03/31/2016 TO 03C31/2017 at <br />12:01 A.M. Standard Time atyour mailing oddnaoa shown above. <br />|noonnderatiommfthe premium reflected, the policy iaamended asindicated below: <br />Anlendiingadditional insured: Addition boread City ofSanta Ana timofficer, employees, agents, <br />Total Annual Total Prorate <br />Total Annual Total Prorate <br />AddidonaVRet m Addi6unmKRetum <br />Tax/Surcharge/Fee $000 Tax/Surcharge/Fee $0.00 <br />Page 1 of 1 <br />