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POLICY NUMBER: 01-CP-0003720-01-22 END: 016 <br />IL P 063 01 16 <br />IL P 063 01 16 © Insurance Services Office, Inc., 2015 Page 1 of 1 <br />CALIFORNIA NOTICE OF DESIGNATED ADDITIONAL <br />PERSON TO RECEIVE NOTICE OF CANCELLATION OR <br />NONRENEWAL <br />SCHEDULE <br />Additional Person To Receive Notice Of Cancellation Or Nonrenewal <br />Name: <Name> <br />Address: <Address> <br />In accordance with CAL INS. CODE § 396, we are notifying you of your right to designate one additional person <br />to receive notice of lapse, termination, expiration, nonrenewal, or cancellation of your policy for nonpayment of <br />premium. <br />You may establish or change the designated person by completing the Schedule and mailing or delivering this <br />completed notice to us. No benefit under your policy is provided to the designated person by this Notice, other <br />than the right to receive the aforementioned notice. <br />Docusign Envelope ID: BAF64511-C271-4FC1-BBE9-5AF1BC605D95