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1 <br />ADDITIONAL INFORMATION- <br />PRODUCER <br />Marsh USA Inc. (Nashville) <br />PO Box 198975 <br />Nashville TN 37219-8975 <br />615-340-2400 Fax615-340-244037219-8975 <br />Attn: Redcross.certrequest@marsh.com <br />DATE IMMIDDl1'1') <br />ATL-001024488-15. 08/21/07 <br />COMPANIES AFFORDING COVERAGE <br />COMPANY <br />E <br />COMPANY <br />F <br />502212-ALL-CAS-07-OB ORAN CA CLIE NONE MAIL <br />INSURED COMPANY <br />ORANGE COUNTY CHAPTER <br />AMERICAN RED CROSS G <br />601 N GOLDEN CIRCLE DR <br />SANTA ANA, CA 92705 <br />COMPANY <br />H <br />ATTACHING TO AND FORMING PART OF THE AMERICAN NATIONAL RED CROSS CERTIFICATE OF INSURANCE <br />AS RESPECTS WORKERS COMPENSATION: <br />This is to certify that all Amedcan National Red Cross units in the following states are currently self insured through the American National Red Cmss <br />Alabama, Califomia, Flodda, Georgia, Massachusetts, Michigan, Missoud, Ohio, Pennsylvania, Tennessee, and Virginia. <br />Workers Compensation Policy #M W C 115192 00: <br />Policy for all other states except the monopolistic states of North Dakota, Puerto Rico, Washington, West Virginia, Wyoming and U.S. Virgin Islands and the <br />self-insured states of Alabama, Califomia, Flodda, Georgia, Massachusetts, Michigan, Missoud, Ohio. Pennsylvania, Tennessee, and Virginia. Includes <br />Employers Liability for monopolistic states of North Dakota, Puerto Rico, Washington, W yoming, and U.S. Virgin Islands. Includes Employers Liability for the <br />monopolistic state of West Virginia, but limited to excess of 100,000f100,000/100,000. <br />'Specific Excess Workers Compensation Policy #MW FEX 123: <br />Amedcan National Red Cross is self-insured for W orkers Compensation in the state of Flodda. The Excess Liability limit is subject to a state approved <br />Self-Insuretl Retention. <br />"Specfc Excess Workers Compensation Policy # MWXS 798: <br />Amedcan National Red Cross is self-insured for W orkers Compensation in the following states: Alabama, Califomia, Georgia, Massachusetts, Michigan, <br />Missouri, Ohio, Pennsylvania, Tennessee and Virginia. The Excess Liability limits are subject to state approved Self-Insured Retentions. <br />This certifcate is issued as a matter of information only and confers no dghts upon the certificate holder. <br />CITY OF SANTA ANA <br />ATTN: JIM STIKELEATHER <br />20 CIVIC CENTER PLAZA, M-24 <br />SANTA ANA, CA 92701 <br />MARSH USA INC. aY <br />Donna D. Bagley ~+~+~--+~ -~- <br />Paae <br />