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LOC #; <br />AGENCY CUSTOMERM; <br />LOC q; <br />AICC>RADDITIONAL REMARKS SCHEDULE 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 /> Untted States <br />CARRIER NAIC <br /> EFFECnVE DATE: <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />POLICIES OF INSURANCE: <br />Policy Number(s) Effective Date(s) Expiration Date(e) <br />WC 026149515 (Tx) 10/1/2010 to/1/2011 <br />WC 026149519 (AOS) 10/1/2010 10/1/2011 <br />WC 025149548 (MN) 10/1/2010 10/1/2011 <br />NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS- <br />a endorsement modifies the notice of cancellation of inaurance provided hereunder; <br />uld any of the above described policies be cancelled before the expiration date thereof, the producer will <br />savor to mail 30 days written notice to the certificate holder named herein, but failure to do so shall <br />oee no obligation or liability of any kind upon the producer, its agents or representatives. <br />other terms and conditions of this policy remain unchanged- <br />ARDINO ADDITIONAL INSpRED STATUS: <br />accordance with the policy provisions, CITY OF SANTA ANA is included as an additional insured under this <br />icy, ae a result of any contract or agreement entered into by the named insured and CITY OF SANTA ANA . <br />er Additional insureds: "The City of Santa Ana, it's officers, employees, agents, and representative are <br />ed as additional insured." <br />\ \ ON Att <br />,?,;,\slaht <br />43 <br />101 <br />& ST?RCorneY <br />® 2008 ACORD <br />The ACORD name and logo are registered marks of ACORD