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III. WORKERS' COMPENSATION <br />EFFECTIVE /EXPIRATION DATE: 11/1/14- 11/1/15 <br />A. INSURANCE COMPANY: Travelers Property and Casual <br />B, AM BEST RATING (A -: VII or greater): A +:XI <br />C. ADMITTED Company (Must be California Admitted): Yes []No <br />D, WORKERS' COMPENSATION LIMIT: Statutory El Yes ❑ No <br />E. EMPLOYERS' LIABILITY LIMIT (Must be $1M or greater) <br />F. WAIVER OF SUBROGATION (To include): is it inoluded? <br />G. SIGNED WORKERS' COMPENSATION EXEMPTION FORM: <br />H. NOTICE OF CANCELLATION: <br />ADDITIONAL COVERAGE'S THAT MAYBE REQUIRED <br />rV. PROFESSIONAL LIABILITY <br />V POLLUTION LIABILITY <br />V BUILDERS RISK <br />HAVE ALL ABOVE REQUIREMENTS BEEN MET? <br />IF NO, WHICH ITEMS NEED TO BE COMPLETED? <br />Approved: <br />ea <br />Agent of Alliant Insurance Services <br />Broker of record for the City of Newport Beach <br />1/29/15 <br />Date <br />1,000,000 <br />® Yes ❑ No <br />® NIA ❑ Yes ❑ No <br />❑ N/A 0 Yes ❑ No <br />❑ NIA ® Yes ❑ No <br />® NIA ❑ Yes ❑ No <br />OEM ffill�m 11 - <br />: - ■ . <br />RISK MANAGEMENT APPROVAL REQUIRED (Non - admitted carrier rated less than _; <br />Self Insured Retention or Deductible greater than $` ) ❑ NIA ❑ Yes ❑ No <br />Reason for Risk Management approvailexception /waiver: <br />Approved; <br />Risk Management Date <br />* Subject to the terms of the contract. <br />25B -41 <br />