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11Q3/2004 15:19 15626942124 SCFRIM ER AGENCY PAGE <br />POLICY NUMHER: 2026652Ss4 COMMffitCIAL GENERAL LIABILITY <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY <br />ADDITIONAL INSURED - OWNERS, LESSEES OR <br />CONTRACTORS - (FORM B) <br />This endorsement modifies insurance provided under the following: <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART. <br />SCHEDULE <br />Name of Person or Organization: <br />CITY OF SANTA ANA. <br />Any person or organization to which you are obligated by virtue of a written contract to <br />Provide innuance such as is afforded by this policy, but only with respect to (1) occurrences taking <br />place after such written contract has been executed and (2) occwrences resulting from work <br />performed by you &umg the policy period. <br />(If no entry appears above, infonmtion irequited to complete this endorsement will be shown in the <br />Declarations as applicable to this endorsement.) <br />WHO IS AN INSURED (Section H) is amended to include as an insured the person or organization shown <br />in the Schedule, but only with respect to liability arising out of "Your work' for that insured by or for you. <br />Coverage provided by this policy to the Additional Inatued(s) shown in the Schedule shall be primary <br />insurance and any other insurance maintained by the Additional Inaured(s) sha11 be excess and non- <br />coatnbatory, but only as respects any claim or liability determined to be the result of the sole negligence or <br />responstbtlity of the Named Insured and only if7 of the Named Insured by written contract. <br />P SO <br />?.Wo 5� RG� fey <br />FS \S a GM <br />O� <br />M, <br />CG 20 10 1185 Copyright, Insurance Services Office, Inc., 1984 Page I of 1 <br />