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AGENCY CUSTOMER ID: <br /> _ LOC#: <br /> Ac oRo® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br /> AGENCY NAMED INSURED <br /> Bernards Bros, Inc. <br /> Willis Towers Watson Insurance Services West, Inc. <br /> 555 First Street <br /> POLICY NUMBER San Fernando, CA 91340 <br /> See Page 1 <br /> CARRIER NAIC CODE <br /> See Page 1 See Page 1 EFFECTIVE DATE:See Page 1 <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br /> FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance <br /> written contract or agreement. <br /> The Excess Liability policy Follows Form. <br /> As respects to Workers Compensation, a Waiver of Subrogation is provided in favor of the Certificate Holder when <br /> required by written contract and as permitted by law. <br /> Contractor's Pollution/Professional Liability continued: $10,000,000 Each Claim - SubGap Indemnity <br /> Self Insured Retention: $100,000 Per Claim <br /> Retroactive Dates: 10/1/2008 Professional Liability <br /> Additional Insureds/Primary and Non-contributory/Waiver of Subrogation: City of Santa Ana, its City Council, officers, <br /> officials, employees, agents, and volunteers. <br /> If required by written contract, the Auto Liability policy includes an Additional Insured endorsement and Waiver of <br /> Subrogation endorsement in favor of Certificate Holder. <br /> Waiver of Subrogation for Workers Compensation: City for all work performed by Consultant, its employees, agents and <br /> sub-contractors. <br /> /_ <br /> Risk Management Division <br /> REVIEWED&APPROVED BY: <br /> ,I'�' Adz Aavzeto <br /> MMMM331 <br /> Risk Management Specialist <br /> ACORD 101 (2008/01) ©2008 ACORD I/ <br /> The ACORD name and logo are registered marks of ACORD <br /> SR ID: 26399028 BATCH: 3610872 CERT: W34651414 <br />