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AGENCY CUSTOMER ID: <br />LOC #: <br />A o® ADDITIONAL REMARKS SCHEDULE <br />Page 2 Of 2 <br />AGENCY <br />NAMED INSURED <br />Willis Towers Watson Insurance Services West, Inc. <br />The Salvation Army - Division 11 <br />30040 Hawthorne Blvd., Bldg D <br />Rancho Palos Verdes, CA 90275 <br />POLICY NUMBER <br />See Page 1 <br />CARRIER <br />NAIC CODE <br />See Page 1 <br />See Page 1 <br />EFFECTIVE DATE: See Page 1 <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 Workers Compensation <br />Policy No. RWES00021610 provides coverage in the fallowing states: AZ,CO,OR <br />Policy No. RWE50004750S provides coverage in the following states: CA <br />CA -Business Auto is fully Self -Insured per the attached State Certificate. <br />City of Santa Ana, its officers, employees, agents, and representatives are included as an Additional Insured as <br />respects to General Liability and Auto Liability as required by written contract or agreement. General Liability pol <br />shall be Primary and Non -Contributory with any other insurance in force for or which may be purchased by Additional <br />Insureds as required by written contract or agreement. Waiver of Subrogation applies in favor of Additional Insureds <br />with respects to Workers Compensation as permitted by law. <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAIC#: 37885 <br />POLICY NUMBER: RWR300094405 EFF DATE: 10/01/2020 EXP DATE: 10/01/2021 <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 />INC - Per Statute E.L. Disease - Ea Emp $1,000,000 <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company NAIC#: 37885 <br />POLICY NUMBER: RWE500047505 EFF DATE: 10/01/2020 EXP DATE: 10/01/2021 <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Excess Workers Compensation E.L. Each Accident $1,000,000 <br />CA EL Each Employee $1,000,000 <br />Retention: $1,000,000 <br />ADDITIONAL REMARKS: <br />CA -Workers Compensation is fully Self -Insured per the attached State Certificate. <br />INSURER AFFORDING COVERAGE: XL Specialty Insurance Company - NAIC#: 37885 <br />POLICY NUMBER: RWE500021610 EFF DATE: 10/01/2020 EXP DATE: 10/01/2021 <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Excess Work Comp- EL Each Accident $1,000,000 <br />AZ/CO/OR EL Each Disease $1,000,000 <br />Retention $750,000 <br />ACORD 101 (2008101) © 2008 ACORD C <br />The ACORD name and logo are registered marks of ACORD <br />rsm% RislcMatmgmadDhislon <br />V RFMEWED&@APPROVED BY. <br />2hk rNanagement Atm(YA(. <br />SR ID: 20160526 BATCH: 1836068 CERT: W18183077 <br />