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POLICY CHANGE DOCUMENT <br /> POLICY NO: CHANGE # 4 CHANGE EFFECTIVE: 09/01/2024 <br /> PHPK2457612-002 <br /> Philadelphia Indemnity Insurance Company PRODUCER: Maguire Insurance Agency, Inc. FWI <br /> NAMED INSURED: Dennys Diaz <br /> MAILING ADDRESS 7143 Fulton Way <br /> Stanton, CA 90680- <br /> POLICY PERIOD: FROM 09/01/2024 TO 09/01/2025 at <br /> 12:01 A.M. Standard Time at your mailing address shown above. <br /> DESCRIPTION: <br /> In consideration of the premium reflected, the policy is amended as indicated below: <br /> Amend Certificate Holder to add Endorsements and Special WordingCity of Santa AnaDelete duplicate <br /> Certificate Holders <br /> Total Annual Total Prorate <br /> Additional/Return Premium $0.00 Additional/Return Premium $0.00 <br /> Total Annual Total Prorate <br /> Additional/Return Additional/Return <br /> TaxWSurcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 <br /> tl„„._..e Riefe�7xn�ent�i?tv€9tcm <br /> REVIEWED&APPROVED BY; <br /> — '—r Page 1 of 1 Risk MlnagernentSpedah5t <br />