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III, WORKERS' COMPENSATION <br />EFFECTIVE /EXPIRATION DATE: 11/1/14- 11/1/15 <br />A. <br />INSURANCE COMPANY: Travelers Property and Casualty <br />B. <br />AM BEST RATING (A-: VII or greater): A+:%I <br />C. <br />ADMITTED Company (Must be California Admitted): <br />® Yes <br />[:]No <br />D. <br />WORKERS' COMPENSATION LIMIT: Statutory <br />® Yes <br />❑ No <br />E. <br />EMPLOYERS' LIABILITY LIMIT (Must be $1M or greater) <br />1,000,000 <br />F. <br />WAIVER OF SUBROGATION (To include): Is it included? <br />® Yes <br />❑ No <br />G. <br />SIGNED WORKERS' COMPENSATION EXEMPTION FORM: <br />® N/A ❑ Yes <br />❑ No <br />H. <br />NOTICE OF CANCELLATION: <br />❑ N/A ® Yes <br />❑ No <br />ADDITIONAL COVERAGE'S THAT MAYBE REQUIRED <br />IV. PROFESSIONAL LIABILITY <br />• POLLUTION LIABILITY ❑ N/A ® Yes ❑ No <br />• BUILDERS RISK <br />® N/A ❑ Yes ❑ No <br />® N/A ❑ Yes ❑ No <br />HAVE ALL ABOVE REQUIREMENTS BEEN MET? ® Yes ❑ No <br />IF NO, WHICH ITEMS NEED TO BE COMPLETED? <br />Approved: <br />3041r� 1/29/15 <br />Agent of Alliant Insurance Services D <br />Broker of record for the City of Newport Beach <br />RISK MANAGEMENT APPROVAL REQUIRED (Non- admitted carrier rated less than _ <br />Self Insured Retention or Deductible greater than $ ) ❑ NIA ❑ Yes ❑ No <br />Reason for Risk Management approval /exception /waiver: <br />Approved: <br />Risk Management Date <br />a Subject to the terms of the contract. <br />