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<br />From: Sandi WFredericksen At: Wood.Gutmann Insurance Brokers FaxlD: 714-573-1772 To: Laura/City of Santa Ana <br /> <br />Date: 3/1512005 11:00 AM Page: 4 of5 <br /> <br />POLICY NUMBER: 042823782 <br /> <br />COMMERCIAL GENERAL LIABILITY <br /> <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> <br />ADDITIONAL INSURED - DESIGNATED PERSON OR <br />ORGANIZATION <br /> <br />This endorsement modifies insurance provided under the following: <br /> <br />COMMERCIAL GENERAL LIABILITY COVERAGE PART. <br /> <br />SCHEDULE <br /> <br />Name Df PerSDn Dr OrganizatiDn: <br /> <br />City of Santa Ana <br /> <br />and their respective officers, employees, <br />agents, volunteers, and representatives <br /> <br />As Required By Wrrtten Contra, <br /> <br />(If no entry appears above, information required to complete this endorsement will be shown in the DeGlarations <br />as applicable to this endorsement.) <br /> <br />WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the <br />Schedule as an insured but only w~h respect to liability arising out of your operations or premises owned by or <br />rented to you. <br /> <br />APPROVED ASrO FORlv! <br />y:?-)) ,1'/11__...., <br /> <br />, La'Jfa SUt\ ~nc';L1j <br /> <br />!\s-.iSlan: CII', <br /> <br />.\; :1)' <br /> <br />CG20261185 <br /> <br />Copyright. Insurance Services Office, Inc.. 1984 <br /> <br />Page 1 of 1 <br /> <br />0 <br />