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HOMEOWNERS <br /> H0 04 41 04 91 <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFUttY. <br /> ADDITIONAL INSURED <br /> Residence Premises <br /> <br /> Name and A(d~dr``ess of Person`or Org`a-ninzation* <br /> C\"C~ ~ .J01~T"~ ~~W <br /> ~ orn~rnun~ ~ e~ A~er~~ <br /> Zp Gw~c, C r~et 4 ~azQ, - <br /> So,~'~v, Pti`nA, C a'L~O~ <br /> The definition of "insured" in this policy includes the person or organization narrtect above with. respect to: <br /> SECTION I <br /> Coverage A -Dwelling and Coverage 6 -Other Structures; and <br /> SECTION II <br /> Coverage E -Personal Liability and Coverage F -Medical Payments to Others but only with respect to the "resi- <br /> dence premises." <br /> This coverage does not apply to "bodily injury" tv and employee arising out of or in the course of the employee's <br /> employment by the person or organization. <br /> If we decide to cancel or not to renew this policy, the party named above will be notified:in writing. <br /> 'Entries may be left blank if shown elsewhere in this ~l~~X for this average. <br /> All other provisions of this policy apply. <br /> POLICY: p~Q2-2,Io~-OOy~~~-~{0 <br /> Chev S;~~e,~cad0 ~ tiC~G EC1~~5Zao6 b0y(o <br /> ~1~~ ~'r. ~~v <br /> ~a~o~a~ C• , C P~ °~~°150. <br /> S1 ORCK <br /> t,1SA E C`ty Attorney <br /> pssistan <br /> HO 04 4.1 04 91 Copyright, Insurance Services Office, Inc., 1990 Page 1 of 1 <br /> <br />