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AGENCY CUSTOMER ID:
<br />LOC
<br />ADDITIONAL REMARKS SCHEDULE Page 2 of
<br />AGENCY
<br />NAMED INSURED
<br />Simplex0rinnell LP
<br />Marsh USA Inc.
<br />12728 Shoemaker Avenue
<br />Santa `0 Springs, CA 90670
<br />POLICY NUMBER
<br />United States
<br />CARRIER
<br />NAIC
<br />EFFECTIVE DATE.
<br />ADDITIONAL REMARKS
<br />THIS ADDITIONAL REMARKS FORM 13 A SCHEDULE TO ACORD FORM,
<br />FORM NUMBER: FORM TITLE: _CERTIFICATE OF LIABILITY INSURANCE
<br />Vr-1`- 1.7 CANCE ILA TION 70
<br />modzf'eti n.t--a -,E
<br />S,,)a,i.d any ol C:._ zbc,,L dez,-,r4 Ced poi, - las on clnce11,f, 2t- -at tI.,am to, non-payrtent of cet,,-- tn_
<br />expiration uate tr.,raof, 33 days ,avl4ce. .f
<br />be dttli, z.d ro certifi.,t
<br />a--r:o-,danc,S with th. pol,oi
<br />A: l oti,e- te-=B and of tr.�s pA. 7y --zr,a±n uar,--..,qad.
<br />In arro, dance wi, tt. thp, FQ Li Cy f,,, j— ns, SANTA ANA POLE a DEPARPIML1,17 it Inc lude i is an -t1 -, 41,na 1 4 nsa d
<br />•mde- this p-li_y, a of on conita.l ew-e ad Into by 'he and SANTA P1,1.4
<br />FCLTCZ DEEP-ATKruDIT.
<br />Ln
<br />to an acLaticnAl insured ,i aoni,/ -o pr,.waLy
<br />inwszanca whpxe reqr.ii°erl by ccntra�t ntzzd 'wL, b-, t named insured and cite SAF177A AITA PA.IC7, 0 EPAX71111,17,.
<br />Alay othn-, insiraa�e -,s-,-,ae6 tc, add�tionrl n,a ed snajj apply a, e,,cetS and
<br />,t! jd ',j, t 4 o., I a C t%, of A, 4 ye -ir 3 -S .,I rHT) -e,,ent a 5
<br />?npj �o, aq�l VoWmte,
<br />- DJARDIFIG WAIVZ� a- Srs',DGP,—Ofl.
<br />In -'_dance w' the Pviiol,43, Lh-, 01 5.�rlog�tn 'ap!)14's .,_r
<br />m,t, -
<br />ov the norred FI,�.rtd and Srv!77A P-11A FSPAR-1,12,11T.
<br />7
<br />11;� 11'N
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<br />FOR QUESTIONS REGARDING THIS CERTIFICATE OF INSURANCE CONTACT:
<br />Kimberly Val, 1ance I Enlail : '-!1 ! 1an -'vs. i Firp, lnrle! 1. com Phone: 562-105-3916)
<br />------------------------------------------------------------------------------------------------------------------------------------------------
<br />THIS CERTIFICATE OF INSURANCE WAS GENERATE[) AND DELIVERED BY F.Xir[S RiskWorkse rmCerehr.,ItecrJ
<br />Process Aw..aticrn for Risk M,111a9m1,rM, h", IIII Trade
<br />— --------
<br />to i0ear a. ,r EX In is can /1,1 burn .,, F 1, 1 Cam nrc -111500 1323 19e3
<br />ACORD 101(2008/01) ©2008 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
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