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AGENCY CUSTOMER ID: <br />LOC N: <br />ACOR" ADDITIONAL REMARKS SCHEDULE <br />Page 2 Of 2 <br />_ <br />AGENCY <br />NAMEDINSURED�-4�- <br />au ..... uu .mu..au,«. n..mvuu. w..m.. ... ...... .... <br />The Salvation Army - DivLeion 11 <br />30040 Hawthorne Blvd., Bldg 0 <br />Banded Palos Verdes, CA 90275 <br />POLICY NUMBER <br />.See Page 1 <br />CARRIER <br />NAIC CODE <br />Sea Page 1 <br />S80 page 1 <br />EFFECTIVE GATE; Soo Page 1 <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 25 FORM TITLE:. Certificate of Liability Insurance 11 <br />Policy No. RWR3000944-04 provides coverage in the following states: AK <br />Policy No, RWE500047504 provides coverage in the following states: CA <br />CA -Work. Comp is fully Self Insured per the attached State Certificate and CA - Auto is fully Self Insured per the <br />attached State Certificate <br />City of Santa Ana, its officers, employees, agents, and representatives are included as an Additional Insured as <br />respects to General Liability and Auto Liability as required by written contract or agreement. General Liability pol.lol <br />shall be Primary and Non -Contributory with any other insurance in force for or which may be purchased by Additional <br />Insureds as required by written contract or agreement. Waiver of Subrogation applies in favor of Additional Insureds <br />with respects to Workers Compensation as permitted by law. <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAICH: 37995 <br />POLICY NUMBER: RWE500047504 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 <br />SUBROGATION WAIVED: Y <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT; <br />Excess Workers Compensation E.L. Each Accident $1,000,000 <br />and Employer's Liability E.L. Disease Pol Lim 41,000,000 <br />WC - Per Statute E.L. Disease - Ea Gap $1,000,000 <br />ADDITIONAL REMARKS: <br />Workers Compensation is Self Insured,. <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAICH: 37885 <br />POLICY NUMBER: RWR3000944-04 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 <br />ADDITIONAL INSURED; Y <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Workers Compensation 6 E.L, Each Accident $1,000,000 <br />Employers Liability E.L. Disease Pol Lim $1,000,000 <br />WC - Per Statute E.L. Disease - Ea Map $1,000,000 <br />INSURER AFFORDING COVERAGE: Greenwich Insurance Company NAICH: 22322 <br />POLICY NUMBER: M5000216-09 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 <br />ADDITIONAL INSURED: Y <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Auto Liability CA Any Auto / CSL $5,000,000 <br />REVIEWED & APPROVED <br />By RISk MANAGrMENT DIVISION <br />03 <br />I,I,ANCIN E(� VU JA�2 iD08 ACORD CORPORATION. <br />The ACORD name and oqo are YOU s are mar cS o AGORD <br />SR ID: 18625509 HATCH: 1395017 CF.RT: W13279389 <br />