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<br />APR~~-2001 17,14 <br /> <br />,ROM-AL L CAL I' <br />\w <br />*POLICYNUMBER: ~{)m "-()2 E /..:2- <br />'lNSUREDCOMPANYNAMI;, ~ -t2'i~~7'~' -:-'-'~ <br /> <br />TmS ENDORSEMENT CHANGES THE POLlCY. PLEASE READ IT CAREFULLY. <br /> <br />0117040160 <br /> <br />'-.J <br /> <br />T-026 <br /> <br />P002/001 ,-171 <br /> <br />_...'-.....,.&~.a:..1.....IW' I. <br /> <br /> <br />ADDITIONAL INSURED - DESIGNATED PERSON or ORGANIZATION <br /> <br />This endorsement modifies ins~e provided under the fbllowing: <br /> <br />. , COMMERCIAL GENERAL LIABIUTY .COVERAGE PART <br /> <br />Name of Person or Organization: <br /> <br />SCHEDULE ; /, <br />Y-~-..,;1.f)OJ / .:J-';;?S--~OlJl <br /> <br />City of Santa Ana and its Officers, Agents, Employees and Volunteers are <br />named as additional insured as respects their interest in connection with the <br />named insured. <br /> <br />(If no entry appears above, infbrmation required to complete this endorsement will be shown in the Declarations <br />as applicable to this endorsement.) <br /> <br />WHO IS AN INSURED (Section II) is amended to include as an insured the person or organi2ation shown in the <br />Schedule, but only with respect to liability arising out of your operations or premises owned by Or rented to you. <br /> <br />IT IS AGREED THAT ANY INSURANCE MAINTAINED BY THE CITY OF SANTA ANA SHALL <br />APPLY IN EXCESS OF, AND NOT CONTRIBUTE WITH, INSURANCE PROVIDED BY TmS <br />POUCY. <br /> <br />Agent'. Signature: <br /> <br /> <br />Jo e t:'S/IJ-Il ~A <br /> <br />CG 2010 II 85 <br />(21 &)C SAMPLE. Act<litionallnsure<l with PrimlllYlNOD-Conb'iburlng Lan~ Added <br /> <br />APPRO"::ED AS TO FORM <br />/ , <br /> <br />