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AGENCY CUSTOMER ID: 570000027366 <br />LOC #: <br />ADDITIONAL REMARKS SCHEDULE Page _ of _ <br />AGENCY <br />ACT Risk services Northeast, Inc. <br />NAMED INSURED <br />Los Angeles SMSA LP <br />POLICY NUMBER <br />See Certificate Number: 570083738856 <br />CARRIER <br />See Certificate Number: 570083738856 <br />NAIC CODE <br />EFFECTIVE DATE: <br />ADDITIONAL REMARKS <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 />ADDITIONAL POLICIES <br />If a policy below does not include limit information, refer to the corresponding policy on the ACORD <br />certificate form for policy limits. <br />POLICY <br />POLICI' <br />INSR <br />ADDL <br />SC BR <br />POLICY NUMBER <br />EFFECTIVE <br />ESPIRATION <br />IIIDIs <br />LTR <br />TYPE OF INSURANCE <br />INSD <br />Ii YD <br />DATE <br />D:1TE <br />(MM/DDA Y1R) <br />(bIM/DDIYIYY') <br />AUTOMOBILE LIABILITY <br />A CA 4594301 06/30/2020 06/30/2021 <br />NH - Primary <br />A CA 4594302 06/30/2020 06/30/2021 <br />NH - Excess <br />COMPENSATION <br />B <br />N/A <br />WC04588b579 <br />06/30/2020 <br />06/30/2021 <br />NV <br />a <br />N/A <br />WC045886577 <br />06/30/2020 <br />06/30/2021 <br />FL <br />D <br />N/A <br />WC043886578 <br />06/30/2020 <br />06/30/2021 <br />MA,ND,OH,WI,WV <br />B <br />N/A <br />wc045886574 <br />06/30/2020 <br />06/30/2021 <br />NI.T .VA <br />ACORD 101 (2008101) <br />© 2008 <br />The ACORD name and logo are registered marks of ACORD <br />REVIEWED & ram.pAPPRwID BY: <br />F'1F1W�r� VJ&44.1 <br />Rok Management Analp I <br />