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AGENCY CUSTOMER ID:
<br /> LOC#:
<br /> ACORIO ADDITIONAL REMARKS SCHEDULE Page of
<br /> AGENCY NAMED INSURED
<br /> Brown&Brown RS Insurance Services,LLC The Howard E.Nyhart Company,Inc.
<br /> 575a apolis IN 4kk Parkway Swte 245
<br /> POLICY NUMBER Indianapolis IN 46250
<br /> 3952-18-14
<br /> CARRIER NAIC CODE
<br /> Great Northern Insurance Company 20303 EFFECTIVE DATE;7/1/2025
<br /> ADDITIONAL REMARKS
<br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
<br /> FORM NUMBER: 25 FORM TITLE:Certificate of Liability Insurance(03/16)
<br /> HOLDER: City of Santa Ana Attn:Finance&Management Services
<br /> ADDRESS:20 Civic Center Plaza Santa Ana,CA 92701
<br /> Workers Compensation States
<br /> *Workers' Comp Policy Number 7174-63-26 includes the following States:
<br /> AR, AZ, CO, CT, FL, GA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MT, NC, NE, NH, NM,
<br /> NV, NY, OK, OR, PA, RI, SD, TN, TX, UT, VA, VT, WV
<br /> **Workers' Comp Policy Number 7177-08-19 includes the following States:
<br /> AL, AR, AZ, CA, DC, DE, FL, IA, ID,
<br /> MA, MS, NJ, NY, PA, RI, SC, WI
<br /> ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD ATTACHMENT
<br /> 90507748 1 XX 7/1/25 Ascensus OnlytProf Liability 25-26 t* 1 excl,XS 1 Judith Botch 15/11/2026 2:02.14 PM (anTI 1 Page 2 of 6
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