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POLICY NO: <br />PHPK803569-008 <br />POLICY CHANGE DOCUMENT <br />CHANGE # 5 CHANGE EFFECTIVE: 12/08/2019 <br />Philadelphia Indemnity Insurance Company I PRODUCER: Maguire Insurance Agency, Inc. FWI <br />NAMED INSURED: Chihiro Sano <br />MAILING ADDRESS 4365 Johanna Ave. <br />Lakewood, CA 90713- <br />POLICY PERIOD: FROM 12/08/2019 TO 12/08/2020 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 />Insured Requested 30 Day Certificate of Insurance shall provide thirty (30) day prior written notice of <br />cancellation <br />Total Annual Total Prorate <br />Additional/Return Premium $0.00 Additional/Retum 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 />& APPROVED <br />\DEMENT DIVISION <br />9 2019 <br />M. <br />