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AGENCY CUSTOMER ID: <br />LOC #: <br />,a OMY ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />AGENCY <br />NAMED INSURED <br />Willis Towers Watson Insurance Services West, Inc. <br />The salvation Army - Division 17 <br />30840 Hawthorne Blvd., Bldg D <br />Rancho Palos Verdes, CA 90275 <br />POLICY NUMBER <br />See Page 1 <br />CARRIER - <br />NAIC CODE <br />See Page 1 <br />See Page 1 <br />EFFECTIVE DATE: See Page 1 <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance <br />FOR USE OF EMERGENCY SOLUTIONS GRANT CORONAVIRUS (ESG-CV) FUNDS. TERM: From: June 15, 2021 through December 31, 2021 <br />The City of Santa Ana, its officers, officials, employees, and volunteers are included as an Additional Insured as <br />respects to General Liability and Auto Liability as required by written contract or agreement. <br />General Liability policy shall be Primary and Non -Contributory with any other insurance in force for or which may be <br />purchased by Additional Insureds as required by written contract or agreement. <br />Waiver of Subrogation applies in favor of Additional Insureds with respects to Workers Compensation, as permitted by <br />law. <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAIC#: 37885 <br />POLICY NUMBER: RWES00047506 EFF DATE: 10/01/2021 EXP DATE: 10/01/2022 <br />SUBROGATION WAIVED: Y <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 />Excess Workers Compensation Policy No. RWEB00047506 provides coverage in the state of CA <br />CA -Workers Compensation is fully Self -Insured per the attached State Certificate <br />ACORD 101 (2008101) © 2108 ACORD C <br />The ACORD name and logo are registered marks of ACORD <br />SR ID: 21630631 BATCH: 2252947 CERT: W22306682 <br />Risk ManagonWntDlvlelon <br />Y Y REVIEWED&.pAP`P'ROVEDBY: <br />tpimp '14rf+CrN�Q <br />[tuk Management Analy5t <br />