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• <br />M. <br />CHANU ENDORSEMENT <br />`J <br />*w <br />CF 12 01 <br />(Ed. 09e5) <br />THIS ENDORSEMENT FORMS A PART OF THE POLICY NUMBERJED BELOW: T T <br />EFFECTIVE DATE <br />COMPANY <br />POLICY NUMBER <br />4 -1 -82 <br />ST. PAUL FIRE & MARINE <br />TERM <br />FROM <br />14-1-83 <br />TO <br />FORM NUMBERS AND EDITION DATES <br />1 <br />4 -1 -82 <br />El <br />CONTRIBUTION % <br />CHANGE <br />IN AMOUNT, <br />RATE, <br />INSUREDS NAME AND MAILING ADDRESS <br />AUTHORIZED REPRESENTATIVE'S NAME AND MAILING ADDRESS <br />ORANGE EMPIRE CONFERENCE <br />R.W. MORTIMER & ASSOCIATES <br />P.O. BOX 5045 <br />P.O. BOX 5609 <br />FULLERTONa CALIFORNIA 92632 <br />BUENA PARKa CALIFORNIA 90620 <br />(9) 1101 (Ill (12) <br />SIGNATURE <br />POLICY CHANGES <br />ADDITIONAL INSURED TO READ: <br />JEFF STEVEN <br />RISK MANAGER <br />20 CIVIC CENTER PLAZA <br />BOX 1988 <br />SANTA ANAE CALIFORNIA 92702 <br />POLICY AMOUNT AND PREMIUM ADJUSTMENT <br />PREVIOUS <br />INCREASE <br />DECREASE <br />NEW <br />PREMIUM <br />DUE AT ENDORSEMENT EFFECTIVE DATE <br />TOTAL POLICY AMOUNT <br />E <br />TOTAL POLICY AMOUNT <br />$ <br />$ <br />It <br />$ <br />11 ADDITIONAL RETURN <br />TOTAL INSTALLMENT PREMIUM <br />M <br />TOTAL INSTALLMENT PREMIUM <br />REPORTING FORM <br />DPP <br />CABLE(PREPAID <br />OR BRET <br />PREVIOUS <br />REMOVAL If the Property covered by this Policy Is removed to a new location described, then, subject to all of as provisions and stipulations, thin Policy shall cover at each location <br />PERMIT during removal, for a period of ten (10) days from effective date of this endorsement, in proportion that the value at each location bears to the value of the property <br />covered by this Policy; and thereafter It shall cover at the new location only. <br />RATING INFORMATION <br />DESCRIPTION OF PROPERTY COVERED (STATE COMPLETE DETAILS REQUIRED FOR RATING) <br />DEDUCTIBLE <br />RATE PUBLICATION NUMBER <br />$100 ALL PERIL. <br />El <br />IF REPORTING FORM <br />STATE POLICY <br />El <br />CONTRIBUTION % <br />CHANGE <br />IN AMOUNT, <br />RATE, <br />OR PREMIUM <br />(1) <br />(2) <br />(3) (4) <br />(5) (61 <br />(7) <br />(8) <br />(9) 1101 (Ill (12) <br />1 <br />AMOUNT Of INSURANCE <br />RATES <br />% <br />TOTAL <br />COMPLETE FOR DEFERRED PREMIUM PAYMENT ONLY <br />T <br />OR <br />'LIMIT <br />PREPAID <br />El <br />OF <br />COINS. <br />PREMIUM DUE <br />FOR REMAINDER <br />PREMIUM DUE EACH ANNIVERSARY <br />PREMIUM <br />E <br />OF LIAHII.ITY IF <br />AP PIT b <br />OF POLICY TERM <br />DUE FOR TRI$ <br />M <br />PERIL <br />REPORTING FORM <br />DPP <br />CABLE(PREPAID <br />OR BRET <br />PREVIOUS <br />NEW <br />CHANGE <br />ENDORSEMENT <br />❑ ADDITIONAL <br />NUMBER OF <br />E] INCREASE <br />ADDITIONAL <br />O <br />PREVIOUS <br />NEW <br />PREVIOUS <br />NEW <br />❑ RETURN- <br />PA <br />DECREASE <br />RETURN <br />RE MA NNNG <br />FIRE <br />$ <br />8 <br />$ <br />$ <br />$ <br />$ <br />$ <br />EC <br />LCIRI <br />TOTALS <br />$ <br />is <br />1 <br />$ <br />is <br />is <br />is <br />$ <br />"RETURN PREMIUM COMPUTED ❑ SHORT RATE ❑ PRO RATA (IF FRO DATA ADVISE REASON) <br />Note: "Premium Due at Endorsement Effective Dale" box —enter the total of Col. (8) if prepaid or the total of Col. (12) if D.P.P. <br />ENDORSEMENT <br />NUMBER <br />CF 12 01 (Ed. 09 75) <br />