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POLICY CHANGE DOCUMENT <br /> POLICY NO: CHANGE # 3 CHANGE EFFECTIVE: 09/01/2025 <br /> P H P K2457612-003 <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 09/01/2025 TO 09/01/2026 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 /> Added Additional Insured with WOS PNC Special WordingCity of Santa Ana, Attention: Parks, Recreation, <br /> and Community Services Agency20 Civic Center Plaza, CA 92701, M-23Santa Ana, CA 92701 <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 /> Tax/Surcharge/Fee $0.00 Tax/Surcharge/Fee $0.00 <br /> Page 1 of 1 <br />