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"v ADDITIONAI <br />AGENCY <br />AGO Risk services Northeast, Inc. <br />POLICY NUMBER <br />see certificate Number: 570083738856 <br />CARRIER <br />see certificate Number: 570083738856 <br />ADDITIONAI <br />AGENCY CUSTOMER ID: 570000027366 <br />LOC #: <br />REMARKS SCHEDULE Page _ of _ <br />NAMEDINSURED <br />LDS Angeles SMSA LP <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance <br />DATE <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURER <br />INSURER <br />INSURER <br />INSURER <br />ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD <br />certificate form for policy limits. <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />11 <br />SDBR <br />W1m <br />POLICY NUMBER <br />POLICY <br />EFFECTIVE <br />DATE <br />(MNBUD/YYYY) <br />POLICY <br />EXPIRATION <br />DATE <br />(MM/DDNYYY) <br />LIMITSINSR <br />AUTOMOBILE LIABILITY <br />A <br />CA 4594301 <br />NH - Primary <br />06/30/2020 <br />06/30/2021 <br />A <br />CA 4594302 <br />NH - EXCESS <br />06/30/2020 <br />06/30/2021 <br />WORKERS COMPENSATION <br />R <br />N/A <br />wc045886579 <br />NY <br />06/30/2020 <br />06/30/2021 <br />B <br />N/A <br />wc045886577 <br />FL <br />06/30/2020 <br />06/30/2021 <br />D <br />N/A <br />wc045886578 <br />M4,ND,OH,WI,WY <br />06/30/2020 <br />06/30/2021 <br />R <br />N/A <br />wc045886574 <br />NI,TX,VA <br />06/30/2020 <br />06/30/2021 <br />ACORD 101 (2008101) u zuuu <br />The ACORD name and logo are registered marks of ACORD <br />REvIE14ED 6 APPROJtD BY: <br />Fv'#'o u R. V:[&vd <br />RBk Management Analyst <br />