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AGENCY CUSTOMER ID: <br /> LOC#: <br /> - ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br /> AGENCY NAMED INSURED <br /> SPECIALTY PROGRAM GROUP LLC/PHS SERVANDO VARELA DBA XV SOLUTIONS <br /> POLICY NUMBER PO BOX 28373 <br /> SEE ACORD 25 SANTA ANA CA 92799-8373 <br /> CARRIER NAIC CODE <br /> SEE ACORD 25 <br /> EFFECTIVE DATE:SEE ACORD 25 <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 /> The City of Santa Ana, its officers, officials, employees, and volunteers are additional insured's per Additional Insured-Owners, <br /> Lessees, or Contractors; Scheduled Person or Organization Form SS4170 and Additional Insured: Owners, Lessees or <br /> Contractors; Completed Operations form SS4171, attached to this policy. Waiver of Subrogation applies in favor of the <br /> Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy. Certificate holder is an additional <br /> insured per the Business Liability Coverage Form SS0008 and the Hired Auto and Non Owned Auto Endorsement SSO438, <br /> attached to this policy. Notice of Cancellation will be provided in accordance with Form SS1223, attached to this policy. <br /> Coverage is primary and noncontributory per the Business Liability Coverage Form SS0008, attached to this policy. <br /> Rime Management DMsim <br /> �?- REVIEWED&APPROVED BY: <br /> °1 IIC I 119 1" A-s-g�e Acevedo <br /> ® Risk Management Specialist <br /> ACORD 101 (2014/01) ©2014 ACORD CORPOF <br /> The ACORD name and logo are registered marks of ACORD <br />