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AC a® <br />AGENCY CUSTOMER ID: CN101348564 <br />LOC #: Los Angeles <br />ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />AGENCY <br />NAMEDINSURED <br />Marsh Risk & Insurance Services <br />AECOM <br />AECOM Technical Services, Inc. <br />999 W, Town and Country Road <br />—.—._._—._—.—..—.._—_..._....—.--...—..—.——_—..—.— <br />POLICY NUMBER <br />Orange, CA 92868 <br />CARRIER <br />NAIC CODE <br />EFFECTIVE DATE: <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: L5 _ FORM TITLE: <br />Workers Compensation/Employer Liability cont <br />Policy Number Insurer <br />WLR O64788759 Indemnity Insurance Company of North America- NAIC # 43575 <br />WLR 064738723 ACE American Insurance Company -NAIC#22667 <br />SCF C64788747 ACE American Insurance Company - NAIC # 22667 <br />WCU C64788802 ACE American Insurance Company - NAIC # 22667 <br />qualified <br />States Covered <br />AOS <br />CA and MA <br />WI Rare <br />OH, Ohio Qualified Self Insured (QSI) - SIR, $500,000, Only applicable to specific <br />entities self -insured in the slate of Ohio <br />ACORD 101 (2008101) <br />The ACORD name and logo are registered marks of ACORD <br />