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POLICY CHANGE DOCUMENT <br /> POLICY NO: CHANGE # 1 CHANGE EFFECTIVE: 10/19/2016 <br /> PH PK1560862-000 <br /> Philadelphia Indemnity Insurance Company PRODUCER: Maguire Insurance Agency, Inc. <br /> NAMED INSURED: Carly Hayden <br /> MAILING ADDRESS PO Box 4238 <br /> Everett, WA 98204- <br /> POLICY PERIOD: FROM 10/05/2016 TO 10/05/2017 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 1 Additional Insured. <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 />