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POLICY NUMBER: 6BRP00000005155500 <br />INTERLINE <br />IL 12 01 11 85 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />POLICY CHANGES <br />Policy Change <br />Number 3 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPG0000005155500 <br />02/07/12 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Judith R Ospina <br />K&K Insurance Group, Inc. <br />DBA: Js Dance Studio <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Form Number: CG2011 "Additional Insured - Managers or Lessors of Premises" <br />[-]Add Form ❑ Delete FormXD Amend Form To Include Additional Insured Below: <br />City of Santa Ana, it's officers, agents and employees <br />Parks, Recreation and Community Services Agency <br />Attn: Donna Schultze <br />1825 W Civic Center <br />Santa Ana, CA 92701 <br />Ref: CP# 2243 <br />The above amendments result in a change in the premium as follows: <br />NO CHANGES <br />TO BE ADJUSTED <br />AT AUDIT <br />ADDITIONAL PREMIUM <br />RETURN PREMIUM <br />Authorized Representative Signature <br />IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />