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AGENCY CUSTOMER ID: <br />LOC fit: <br />ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />AGENCY NAMED INSURED <br />Marsh, Inc. SimplexGrinnell, LP <br />POLICY NUMBER 1701 WEST SEQUOIA AVE <br /> ORANGE, CA 92868 <br /> United States <br />CARRIER NAIC <br /> EFFECTIVE DATE: <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACQRD FORM, <br />FORM NUMBER: 75 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />REGARDING POLICIES OF INSURANCE: <br />Insurer Policy Number() Effective Date (s) Expiration Data (s) <br />F WC 026149sis (TX) 10/l/2010 10/1/207.1 <br />F WC 026149519 (AOS) 10/i/2010 1011/2011 <br />F WC 026149546 (MN) 10/1/2010 10/1/2011 <br />NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS: <br />endorsement modifies the notice of cancellation of insurance provided hereunder: <br />uld any of the above described policies be cancelled before the expiration date thereof, the producer will <br />savor to mail 20 days written notice to the cprcificate holder named herein, but failure to do So Shall <br />sae no obligat?.on or liability of any kind upon the producer, its agents or representatives. <br />other terms and conditions of this policy remain unchanged- <br />ARDING ADDITIONAL 1N$VA2h $TATV9: <br />accordance faith the policy provi?ions, CITY OF SANTA AMA is included as an additional insured under this <br />icy, as a result of any contracr, or agreement entered into by the named insured and CITY OF SANTA ANA . <br />er Additional znsureds: "The City of Santa Ana, it's officers, employees, agents, and representative are <br />ed as additional insured." <br />V .0 <br />E, S'??R o?ney <br />43 <br />ACQRD 101 (2008/01) Q) 2008 ACQRD CORPORATION. All rights reserved, <br />The ACQRD namee and logo are registered marks ofACORD <br />