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AGENCY CUSTOMER ID: <br />LOC #: <br />ADDITIONAL REMARKS SCHEDULE <br />AGENCY �Hawthor� <br />Willis Towers Watson Insurance Services West, Inc. y - Division 11 <br />l vd., Bltlg D <br />POLICY NUMBER <br />es, CA 90275 <br />See Page 1 <br />CARRIER <br />See Page 1 <br />NAICCODE <br />See Page 1 rEFFECTIVE DATE: Sae Page 1 <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance <br />Excess Workers Compensation RW Policy No. E500021610 provides coverage in the following states: AZ,CO,OR <br />Policy No. RWES00047505 provides coverage in the following states: CA <br />CA -Business Auto is fully Self -Insured per the attached State Certificate. <br />Page 2 of 2 <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 <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 <br />POLICY NUMBER: RWR300094405 EFF DATE: 10/01/2020 EXP DATE: 10/01/2021 <br />'TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Workers Compensation S 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 Emp $1,000,000 <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company <br />POLICY NUMBER: RWE500047505 EFF DATE: 10/01/2020 EXP DATE: 10/01/2021 <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Excess Workers Compensation E.L. Each Accident $1,000,000 <br />CA EL Each Employee $1,000,000 <br />Retention; $1,000,000 <br />ADDITIONAL REMARKS: <br />CA -Workers Compensation is fully Self -Insured per the attached State Certificate. <br />INSURER AFFORDING COVERAGE; XL Specialty Insurance Company <br />POLICY NUMBER: RWES00021610 EFF DATE: 10/01/2020 EXP DATE: 10/01/2021 <br />TYPE OF INSURANCE: <br />Excess Work Comp- <br />AZ/CO/OR <br />101 (2008/01) <br />LIMIT DESCRIPTION: <br />EL Each Accident <br />EL Each Disease <br />Retention <br />LIMIT AMOUNT: <br />$1,000,000 <br />$1,000,000 <br />$750,000 <br />© 2000 <br />NAIC#: 37885 <br />NAIC#: 37885 <br />NAIC#: 37885 <br />riahts <br />1 nu nwrtu name ana 1000 are registered marks of ACORD <br />SR ID; 20160526 BATCH: 1836068 CENT; W18183077 <br />