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AGENCY CUSTOMER ID: <br />LOC#: <br />ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />AGENCY <br />NAMEDINSURED <br />AUTOMATIC DATA PROCESSING INS AGCY <br />JACOB GREEN AND ASSOCIATES INC. <br />13217 JAMBOREE RD # 248 <br />POLICY NUMBER <br />SEE ACORD 25 <br />TUSTIN CA 92782-9158 <br />CARRIER <br />NAIC CODE <br />SEE ACORD 25 <br />EFFECTIVE DATE: SEE ACORD 25 <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM <br />FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />Blanket Waiver of Subrogation applies in favor of the City of Santa Ana, its City Council, officers, officials, employees, agents <br />and volunteers per the Waiver of Our Right to Recover from Others Endorsement WC040306, attached to this policy. Notice <br />of Cancellation will be provided in accordance with Form WC990394, attached to this policy. RE; State job is performed in: <br />CA, Project / Location: JGA Organizational Development Services / City of Santa Ana <br />ADDITIONAL REMARKS <br />ACORD 101 (2014101) © 2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />