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POLICY NUMBER: 57 SBM BL2522 <br />CHANGE NUMBER: 003 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />ADDITIONAL INSURED - OWNERS, LESSEES OR <br />CONTRACTORS - COMPLETED OPERATIONS <br />This endorsement modifies insurance provided under the following: <br />BUSINESS LIABILITY COVERAGE FORM <br />SCHEDULE <br />Name Of Additional Insured Person(s) Or Organization(s): <br />THE CITY OF SANTA ANA <br />Location And Description Of Completed Operations: <br />20 CIVIC CENTER PLZSANTA ANA, CA 92701 <br />Information required to complete this Schedule, if not shown above, will be shown in the Declarations. <br />Section C. — Who Is An Insured is amended to <br />include as an additional insured the person(s) or <br />organization(s) shown in the Schedule, but only with <br />respect to liability for "bodily injury" or "property <br />damage" caused, in whole or in part, by "your work" <br />at the location designated and described in the <br />schedule of this endorsement performed for that <br />additional insured and included in the "products - <br />completed operations hazard". <br />Form SS 41 71 06 11 <br />Process Date: 11/12/18 <br />e�G <br />Page 1 of 1 <br />Policy Expiration Date: 11/09/19 <br />© 2011, The Hartford <br />(Includes copyrighted material of Insurance Services Office, Inc., with its permission) <br />