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AGENCY CUSTOMER ID: 570000027366 <br />i1 LOC III:A� �® ADDITIONAL REMARKS SCHEDULE <br />AGENCY <br />AOn Risk Services Northeast, Inc. <br />POLICY NUMBER <br />See certificate Number: 570083738856 <br />CARRIER <br />see certificate Number: 570083738856 <br />ADDITIONAL <br />Los Angeles SMSA LP <br />EFFECTIVE DATE <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURER <br />INSURER <br />INSURER <br />INSURER <br />1l <br />Page -of _ <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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSR <br />SUER <br />WVD <br />POLICYNUMBER <br />POLICY <br />EFFECTIVE <br />DATE <br />(MM/DDAI 'Y) <br />POLICY <br />ESPIR\TION <br />DATE <br />(MM/DD/4YYY) <br />LnIITS <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 />g <br />N/A <br />wc045886577 <br />FL <br />06/30/2020 <br />06/30/2021 <br />D <br />N/A <br />wc045886578 <br />MA,ND,OH,WI,WY <br />06/30/2020 <br />06/30/2021 <br />8 <br />N/A <br />wc045886574 <br />NI,TX,VA <br />06/30/2020 <br />06/30/2021 <br />ACORD 101 (2008/01) <br />The ACORD name and logo are registered marks of ACORD <br />©2008 ACORD XIaR APva'gvnm[ utwelon <br />RenEwED 6 APPRCN® Sr. <br />®' RDk Management Analyst <br />