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AGENCY CUSTOMER ID: <br />LOC #: <br />A� ° <br />ADDITIONAL REMARKS SCHEDULE Page 2of10 <br />AGENCY <br />NAMEDINSURED <br />REPUBLIC SERVICES, INC. <br />POLICY <br />NUMBER <br />See First Page <br />18500 N. ALLIED WAY <br />PHOENIX, AZ 85054 <br />CARRIER <br />NAIC CODE <br />See First Page <br />EFFECTIVE DATE: <br />ADDITIONAL REMARKS <br />CERTIFICATF NIIMRFR- inAAgi¢ <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM. <br />FORM NUMBER: 25 FDRM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />The following provisions apply when required by written contract. As used below, the term certificate holder also includes any person or organization that <br />the insured has become obligated to include as a result of an executed contract or agreement. <br />GENERAL LIABILITY: <br />Certificate holder is Additional Insured including on -going and completed operations when required by written contract. <br />Coverage is primary and non-contributory when required by written contract. <br />Waiver of Subrogation in favor of the certificate holder is included when required by written contract. <br />AUTO LIABILITY: <br />Certificate holder is Additional Insured when required by written contract. <br />Coverage is primary and non-contributory when required by written contract. <br />Waiver of Subrogation in favor of the certificate holder is included when required by written contract. <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY: <br />Waiver of Subrogation in favor of the certificate holder is included when required by written contract where allowed by slate law. <br />Stop gap coverage for NO, WA and WY is covered under policy no. WLR C67824064 and stop gap coverage for OH is covered under policy no. WCU <br />C67824143, as noted on page 1 of this certificate. <br />TEXAS EXCESS INDEMNITY AND EMPLOYERS LIABILITY: <br />Insured is a registered non -subscriber to the Texas Workers Compensation Act. Insured has filed an approved Indemnity Plan with the Texas <br />Department of Insurance which offers an alternative in benefits to employees rather than the traditional Workers Compensation Insurance in Texas. The <br />excess policy (#TNS C68990592) shown on this certificate provides excess Indemnity and Employers Liability coverage for the approved Indemnity Plan. <br />Contractual Liability is included in the General Liability and Automobile Liability coverage forms. The General Liability and Automobile Liability policies do <br />not contain endorsements excluding Contractual Liability. <br />Separation of Insured (Cross Liability) coverage is provided to the Additional Insured, when required by written contract, per the Conditions of the <br />Commercial General Liability Coverage form and the Automobile Liability Coverage form. <br />Re: RFP21-097 - East Alton Avenue Lot License Agreement <br />Additional Insured includes: City of Santa Ana, its officers, employees, agents, volunteers and representatives, when required by written contract. <br />REVIEWED & APPROVED Br. <br />Risk Management Specialist <br />.......... ©1988-2010 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />