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AGENCY CUSTOMER ID: 570000027366 <br />LOC #: <br />'4 ADDITIONAL REMARKS SCHEDULE <br />r. <br />Page _ of _ <br />AGENCY <br />AOn Risk services Northeast, Inc. <br />NAMED INSURED <br />LDS Angeles SMSA LP <br />POLICY NUMBER <br />See certificate Number: 570083738856 <br />CARRIER <br />see certificate Number: 570083738856 <br />NAIC CODE <br />EFFECTIVE DATE: <br />ADDITIONAL REMARKS <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance <br />11 INSURER(S) AFFORDING COVERAGE I NAIC # <br />II ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD <br />certificate form for policy limits. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />WVp <br />POLICY NUMBER <br />POLICY <br />EFFECTIVE <br />DATE <br />(MMMDN\ YI <br />POLICY <br />EXPIRATION <br />DATE <br />(MM/DDNYYY) <br />LIMITS <br />AUTOMOBILE LIABILITY <br />A <br />Ca. 4594301 <br />NH - Primary <br />06/30/2020 <br />06/30/2021 <br />A <br />CA 4594302 <br />NH - EXCeSS <br />06/30/2020 <br />06/30/2021 <br />WORKERS COMPENSATION <br />R <br />N/A <br />wc045886579 <br />NY <br />06/30/2020 <br />06/30/2021 <br />R <br />N/A <br />wc045886577 <br />FL <br />06/30/2020 <br />06/30/2021 <br />D <br />N/A <br />wc045886578 <br />MA,ND,OH,WI,WY <br />06/30/2020 <br />06/30/2021 <br />B <br />N/A <br />wc045886574 <br />NI,TX,VA <br />06/30/2020 <br />06/30/2021 <br />ACORD 101 (2008101) © 2008 <br />The ACORD name and logo are registered marks of ACORD <br />RideMmogmlE DMsLm <br />REVIEWED 6 APPROVED Br. <br />Z Vj&'dAl <br />Risk Management Analyst <br />