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POLICY NO: <br />PHPK1473665-000 <br />POLICY CHANGE DOCUMENT <br />CHANGE # 5 CHANGE EFFECTIVE: 04/11/2016 <br />Philadelphia Indemnity Insurance Company ! PRODUCER: Maguire Insurance Agency, Inc. <br />NAMED INSURED: Connie McGuire <br />MAILING ADDRESS 539 E Washington Ave <br />Orange, CA 92366- <br />POLICY PERIOD: FROM 03/31/2016 TO 03/3112.017 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 />Amending additional insured: Addition to read City of Santa Ana tis officer, employees, agents, <br />representatives & volunteers. Plus 30 NOC <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 />VIP" P\Ne d i <br />'C � <br />Page 1 of 1 <br />