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Wk=. <br />INSURANCE <br />Coverage Is Provided In: <br />West American Insurance Company - a stock company <br />Policy Change Endorsement <br />Policy Number: <br />BKW (21) 60 62 24 86 <br />Policy Period: <br />From 01/01/2020 To 01/01/2021 <br />Endorsement Period: <br />From 01/01/2020 to 01/01/2021 <br />12:01 am Standard Time <br />at Insured Mailing Location <br />Named Insured & Mailing Address Agent Mailing Address & Phone No. <br />GERALDINE VALENCIA <br />DBA: G STARS DANCE AND GYMNASTICS <br />940 W CHAPMAN AVE STE 103C <br />ORANGE, CA 92868 <br />CHANGES TO POLICY - TRANSACTION 4 2 <br />(714) 288-8000 <br />AA LARES INSURANCE SERVICES INC <br />PO BOX 4817 <br />ORANGE, CA 928634817 <br />This Policy Change Endorsement Results In A Change In The Charges As Follows: <br />Additional Premium <br />Total Additional Charges <br />Certified Acts of Terrorism Additional Charges <br />Description of Change(s) <br />The additional insured form CG2010, Notice of <br />Cancellation form CG8061, and the Primary <br />Non -Contributory form CG2001 are added for the <br />following: City of Santa Ana Risk Management <br />Division - 20 Civic Center Plaza Santa Ana, CA <br />92702. <br />By RiskM N�& MENT DilivliSiON <br />I 1%/ i' 1 <br />r <br />$79.00 <br />$79.00 <br />$1,00 (Included) <br />Note: This is not a bill <br />Issue Date 01/23/20 Authorized Representative <br />To report a claim, call your Agent or 1-844-325-2467 <br />DS 70 27 01 08 <br />nlni/9n MA714AR hinniimi; Wan Nr APPPNn INSIIRPn rn Pv nn7779 Parr, i nP 17 <br />