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AGENCY CUSTOMER ID: <br />LOC#: <br />ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />AGENCY <br />NAMED INSURED <br />SPECIALTY PROGRAM GROUP LLC/PHS <br />SERVANDO VARELA DBA XV SOLUTIONS <br />PO BOX 28373 <br />POLICY NUMBER <br />SEE ACORD 25 <br />SANTA ANA CA 92799-8373 <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 />The City of Santa Ana, its officers, officials, employees, and volunteers are additional insured's per Additional Insured- Owners, <br />Lessees, or Contractors; Scheduled Person or Organization Form SS4170 and Additional Insured: Owners, Lessees or <br />Contractors; Completed Operations form SS4171, attached to this policy. Waiver of Subrogation applies in favor of the <br />Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy. Certificate holder is an additional <br />insured per the Business Liability Coverage Form SS0008 and the Hired Auto and Non Owned Auto Endorsement SSO438, <br />attached to this policy. Notice of Cancellation will be provided in accordance with Form SS1223, attached to this policy. <br />Coverage is primary and noncontributory per the Business Liability Coverage Form SS0008, attached to this policy. <br />„ Riak Mmaganenf DMsian <br />�?- REVIEWED & APPROVED BY: <br />°1 IIC I 119 1" A-s-g�e Acevedo <br />® Risk Management Specialist <br />ACORD 101 (2014/01) © 2014 ACORD COI <br />The ACORD name and logo are registered marks of ACORD <br />