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AGENCY CUSTOMER ID: <br />LOC #: <br />A O ADDITIONAL REMARKS SCHEDULE <br />Page 2 Of 2 <br />AGENCY <br />NAMEOINSURED <br />The Salvation Arn, - Division 11 <br />30840 Hawthorne Blvd., Bldg D <br />Rancho Palo. Verdes, CA 90275 <br />POLICY NUMBER <br />See Page 1 <br />CARRIER <br />NAIL CODE <br />See Page 1 <br />800 Page 1 <br />EFFECTIVE DATE: See Page I <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 2S FORM TITLE: Certificate of Liability Insurance <br />Policy No. RWR3000944-04 provides coverage in the following states:AX <br />Policy No. RWE500047504 provides coverage in the following states: CA <br />CA -Work. Comp is fully Self Insured per the attached State Certificate and CA - Auto <br />is fully Self Insured per the <br />attached State Certificate <br />City of Santa Ana, its officers, employees, agents, and representatives are included <br />as an Additional Insured as <br />respects to General Liability and Auto Liability as required by written contract or agreement. General Liability pulley <br />shall be Primary and Non -Contributory with any other insurance in force for or which <br />may be purchased by Additional <br />Insureds as required by written contract or agreement. Waiver of Subrogation applies <br />in favor of Additional Insureds <br />'I with respects to Workers Compensation as permitted by law. <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company <br />NAICN: 37885 <br />POLICY NUMBER: RWES00047504 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 <br />SUBROGATION WAIVED: Y <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT; <br />Excess Workers Compensation E.L. Each Accident 0 000,000 <br />and Employer's Liability E.L. Disease Pol Lim $1,000,000 <br />WC - Per Statute E.L. Disease - Ea Emp $1,000,000 <br />ADDITIONAL REMARKS:- <br />Workers Compensation is Self Insured, <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company <br />POLICY NUMBER: RWR3000944-04 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 <br />ADDITIONAL INSURED: Y <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Workers Compensation & E.L, Each Accident $1,000,000 <br />Employers Liability E.L. Disease Pol Lim $1,000,000 <br />WC - Per Statute E.L. Disease - Ea Emp $1,000,000 <br />INSURER AFFORDING COVERAGE: Greenwich Insurance Company <br />POLICY NUMBER: RAE5000218-09 EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 <br />ADDITIONAL INSURED: Y <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Auto Liability - CA Any Auto / CSL $5,000,000 <br />REVIEWED & APPROVED <br />By Risk MIANFlGEMENT DivisiON <br />T 0 3 19 <br />ACORD 101 (2008101) na IT A,QNEA �„ I� ��S}'2008ACORD <br />The ACORD name BIt ego are reg s Gre mar s O ACORD <br />SR ID: 18625509 HATCH: 1395017 CURT: W13279389 <br />NAIL#: 37BB5 <br />NAICN: 22322 <br />