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AGENCY CUSTOMER ID:JLEEENG-01 MICHAELA <br /> LOC#: 1 <br /> AC40ROADDITIONAL REMARKS SCHEDULE Page 1 of 1 <br /> AGENCY License#OE67768 NAMED INSURED <br /> IOA Insurance Services JLee Engineering,Inc. <br /> 3871 E Colorado Boulevard,Suite 200 <br /> POLICY NUMBER Pasadena,CA 91107 <br /> EE PAGE 1 <br /> CARRIER WC CODE <br /> EE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 <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 /> Description of Operations/LocationsfVehicles: <br /> GENERAL LIABILITY ADDITIONAL INSURED INCLUDES THE FOLLOWING PERSON(S)OR ORGANIZATION(S): City of Santa Ana, its <br /> officers, employees,and authorized agents <br /> ACORD 101 (2008101) p 2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />