OLD REPUBLIC GENERAL INSURANCE CORPORATION
GENERAL LIABILITY
CHANGE POLICY EXP DATE
POLICY NO.
END:
ACCOUNT NUMBER: W060
NAMED INSURED AND MAILING ADDRESS AGENCY AND MAILING ADDRESS City of San Mateo ALLIANT INSURANCE SERVICES, INC.
Address 701 B. STREET, 6TH FLOOR
SAN DIEGO, CA 92101
POLICY PERIOD: FROM DATE TO DATE AT 12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE.
Effective: DATE expiration date is amended as shown above.
TOTAL ADDITIONAL PREMIUM DUE FOR THIS ENDORSEMENT XXXXX
TOTAL ADDITIONAL AMOUNT DUE FOR THIS ENDORSEMENT XXXXX
COUNTERSIGNED BY:
AUTHORIZED REPRESENTATIVE DATE
CGENGN0109 06 13 06-28-24 Page 1 of 1 SN opereyra