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POLICY CHANGE (Continued) <br />Policy Number: 76 SBU 9c5868 <br />Policy Change Number: 001 <br />IH12001185 ADDITIONAL INSURED - PERSON -ORGANIZATION <br />REVIEWED & APPROVED <br />By Risk MANAGEMENT DIVISION <br />Form SS 12 1104 05 T T 03 2 19 ) Page 002 <br />Process Date: 10/02/19 <br />FRANCINE R. VILLAREAL <br />Policy Effective Date: 08/14/19 <br />Policy Expiration Date: 08/14/20 <br />