THE SALVATION ARMY OF ORANGE COUNTY

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AGENCY CUSTOMER ID: LOC #; L_ ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED xu • x v„, xw, a.rvw , The 8e1vation Army - Division 11 30840 Hawthorne Blvd., eldg 0 Rancho Palos Vardes, CA 90275 POLICY NUMBER See Page 1 CARRIER NAIC CODE See Page 1 Soo Page 1 EFFEC71VE DATE: See Page 1. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE:. Certificate of Liability Insurance Policy No: RWR3000944-04 provides coverage in the following states: AX Policy No. RWZ500047504 provides coverage in the following states: CA CA -Work. Camp is fully Self Insured per the attached State Certificate and CA - Auto is fully Self Insured Paz the attached State Certificate City of Santa Ana, its officers, employees, agents, and representatives are included as an Additional Insured as respects to General Liability and Auto Liability as required by written contract or agreement. General Liability .pal shall be Primary and Non -Contributory with any other insurance in force for or which may be purchased by Additional Insureds as required by written contract or agreement. Waiver of Subrogation applies in favor of Additional Insureds with respects to Workers Compensation as permitted by law. INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAIC#: 37885 POLICY NUMBER: RWES00047504 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 SUBROGATION WAIVED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT; Excess Workers Compensation E,L. Each Accident $1,000,000 and Employer's Liability E.L. Disease Pal Lim $1,000,000 WC - Per Statute E.L. Disease - Ea Emp $1,000,000 ADDITIONAL REMARICS: Workers Compensation is Self Insured, INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAICW: 37885 POLICY NUMBER: RWR3000944-04 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 ADDITIONAL INSURED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation 6 E.L. Each Accident $1,000,000 Employers Liability E.L. Disease Pal Lim $1,000,000 WC - Per Statute E.L. Disease - Ra Emp $1,000,000 INSURER AFFORDING COVERAGE: Greenwich Insurance Company NAIC#: 22322 POLICY NUMBER: RAES000210-09 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 ADDITIONAL INSURED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Auto Liability - CA Any Auto / CSL 0,000,000 REVIEWED & APPROVED By Risk MANAGF_MENT DIVISION AA . 0.C1.03 2019 r, 101 �;?ANCI rF (' V, t LA�2E . 'C11 ACORD CORPORATION. All rights The ACORD name Dud D, o are tog s are mar is o ACORD SR ID: 18625509 BATCH: 1395017 CER'f: W13279389