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AGENCY CUSTOMER ID: <br />LOC #: <br />® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br />NAMED IN SURED <br />USf�It1C. SimplexGrinnell, LP <br />NUhftlEN '170'1 WEST SEQUOIA AVE <br />ORANGE, CA 92868 <br />United States <br />t NAIC <br />_ I I EFFEC TIVE DATE: <br />AdbltIONAL REMARKS <br />THIS ADb(YYO NAL T�EINARKS FORM IS A SCHEDULE TO ACORD FORM, <br />F0131V) NUNi19ER: - z9 I =ORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />REGARDING POLICIES bF INSURANCE: <br />InsiiYLY Policy dumber (a) Effective Date (s) Expiration Dates) <br />F WC tl1SeB4009 (MN) 10/1/2011 10/1/2012 <br />F WC bi5894003 (AOS) 10/1/2011 10/1/2012 <br />REGARDING NOTI Ctn OP' CANCELLATION TO CERTIFICATE HOLDERS <br />Thi9 elidoYeement modifies the notice of Cancellation O£ insurance provided hereunder: <br />'S hdiild arty of tfff3 above described policies be cancelled, other than £or non - payment of premium, before the <br />expiratidSt date thereof, 30 days advice of cancellation will be delivered to certificate holders in <br />accordance with the policy endorsements. <br />All otheY t:e rrt(a and conditions o£ this policy remain unchanged. <br />REGARDING AIiDYT�lONAL INSURED STATUS <br />In aCCOrdgtfce 4/1.th the policy provisions, SANTA ANA POLICE DEPARTMENT is included as an additional insured <br />un�elP this �oliCy, as a result of any contract or agreement entered into by the named insured and SANTA ANA <br />POLICE D1•"�ARTMENT. <br />In aC C'brciaiice with the policy provisions, coverage afforded to an additional insured will apply as primary <br />instil' art t:e Where required by cont rac t entered into by the named insured and the SANTA ANA POLICE DEPARTMENT . <br />Any other insurance issued to such additional insured shall apply as excess and noncontributory insurance. <br />OtheY Additional Insureds: The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its <br />officers. employees, agents, volunteers and representatives are named as additional insureds (�� additional <br />Insureds "i with Yegard to libability and defense of suite arising from the operations and urea performed by <br />or on behalf of the named insured. <br />REGARDINd WAIVER OF SUBRGGATION: <br />In accordance with the pclicy provisions, the Waiver of Subrogation applies per contract or agreement entered <br />into by the named Insured and SANTA ANA POLICE DEPARTMENT . <br />FOR QUBSi1bN5 fZ�GARDING THIS CERTIFICATE OF INSURANCE CONTACT: <br />Ji1liaYi Htichatfan (Email: jilbuchanan�eimplexgrinnell.com Phone: 714 -870 -1010) <br />tttls Certilleata of Insurance was generatetl by EXIGIS RISKworks® rm.Cartlflcates ®.To learn more about EXIGIS Certifl cats Management Solutions visit www.ex191s.co m /tyc. <br />ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />