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AGENCY CUSTOMER ID: 33004270 <br />LOCH <br />Paged of <br />`'` °R°? ADDITIONAL REMARKS SCHEDULE <br />AGENCY NAMED INSURED <br /> Care Ambulance Service, Inc. <br />Willis of New York, Inc. 1517 Braden Court <br />POLICY NUMBER Orange, CA 92868 <br />See First Page <br />CARRIER ;?E <br />See First Page [ EFFECTNEDATE See First Page <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 />Excess Liability <br />Policy# TH7-631-510005-042 <br />Effective/Expiration: 10/01/2012-10/01/2013 <br />Carrier: Libert Insurance Corporation <br />Limits of Liability: $5,000,001) Per occurrence/$5,000,000 Aggregate <br />The City of Santa Ana and OCFA, and their respective officers, officials, employees, <br />representatives and volunteers are hereby declared to be additional insured, as respects <br />operations, activities, works, errors or omissions of the named insured arising out of or <br />connection with any contract or agreement with the City of Santa Ana. <br />This insurance is primary to, and shall not contribute with, any insurance or self-insurance <br />maintained by the CITY of SANTA Ana, by OCFA, or by any of the designated additional insureds. <br />This insurance shall apply separately to each insured against whom claim is made or suit is <br />brought, except with respect to the limits of the insurer's liability. <br />Waiver of subrogation applies in favor of certificate holder under the workers compensation and <br />professional liability policies. <br />ACORD101 (2008101) Coll:3901342 Tpl:1522613 Cert:18767380 ®2008ACORDCORPORATION. Allrights reserved. <br />The ACORD name and logo are registered marks of ACORD