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AGENCY CUSTOMER ID: 570000027366 <br />LOC #: <br />ADDITIONAL REMARKS SCHEDULE <br />Page _ of _ <br />AGENCY <br />Ann Risk Services Northeast, Inc. <br />NAMED INSURED <br />LOS Angeles SMSA LP <br />POLICYNUMBER <br />see Certificate Number: 570107777870 <br />CARRIER <br />see certificate Number: 570107777870 <br />NAIL CODE <br />EFFECTIVE DATE: <br />ADDITIONAL REMARKS <br />THIS ADDITIONAL REMARKS FORM IS ASCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURER <br />INSURER <br />INSURER <br />INSURER <br />ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD <br />certificate form for policy limits. <br />UNSlVPOLICYNUADtER ILRITS <br />LLTR TYPEOFINSURANCE DWD DATE <br />(aMW IOD <br />WORKERS COMPENSATION <br />R I I NIA <br />MA <br />ACORD 101 (200ElDI) © 2008 ACOI <br />The ACORD name and logo are registered marks of ACORD <br />REAEwEO I <br />'� Risk Management Spenalist <br />