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AGENCY CUSTOMER ID: <br />LOC#: <br />ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />AGENCY <br />NAMED INSURED <br />HUB INTL MOUNTAIN STATES LTD/PHS <br />MARTHA VAN ROOIJEN DBA MVR CONSULTING <br />PO BOX 236 <br />POLICY NUMBER <br />SEE ACORD 25 <br />CALIMESA CA 92320-0236 <br />CARRIER <br />NAIC CODE <br />SEE ACORD 25 <br />EFFECTIVE DATE: SEE ACORD 25 <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 />Notice of Cancellation will be provided in accordance with Form SL9013, attached to this policy. Waiver of Subrogation applies <br />in favor of the Certificate Holder per the Business Liability Coverage Form SL 00 00, attached to this policy. The Business <br />Liability Coverage Part includes City of Santa Ana, its City Council, officers, officials, employees, agents, and volunteers are <br />Blanket Additional Insured By Contract Endorsement, Form SL 30 32. RE: Job Description/Contract Number: Software <br />Maintenance Support <br />ACORD 101 (2014/01) © 2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />