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AGENCY CUSTOMER ID: CN101348564 <br /> ��,,,,� LOC#: Los Angeles <br /> ��C,,,�,R�� ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br /> AGENCY NAMEDINSURED <br /> Marsh Risk&Insurance Serviceso AECOMo <br /> 345 East Ash Avenueo <br /> POLICY NUMBER Decatur,IL 62526 <br /> CARRIER <br /> NAIC CODE <br /> EFFECTIVE DATE: <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br /> FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance <br /> i, <br /> o � <br /> Workers Compensation/Empioyer Liability conl� <br /> u <br /> Policy Number Insurer States Covered'! <br /> WLR C6589323A Indemnity Insurance Company of North Amerira-NAIC#43575 AOSI <br /> WLR C65893150 ACE American Insurance Company-NAIC#22667 CA and MN� <br /> SCF C65893198 ACE American Insurance Company-NAIC#22667 WI Retrotl <br /> WCU C65893393 ACE American Insurance Company-NAIC#22667 OH,Ohio Qualified Self Insured(QSI)-SIR:$500,000;Only applicable to specific <br /> qualified�� <br /> entities self-insured in the state of Ohia <br /> u : <br /> ACORD 104(2008/01) O 2008 ACORD CORPORATiON. Atl rights reserved. <br /> The ACORD name and logo are registered marks of�+,CORD <br />