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r ri,r+ <br />i <br />City of Sunny Isles Beach Construction Management Services <br />For Gateway Park - RFQ No. 12 -06 -01 <br />AGENCY CUSTOMER ID: URSCOR <br />LOC #: San Francisco <br />Accoo ® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br />AGENCY <br />MARSH RISK & INSURANCE SERVICES <br />NAMEDINSURED <br />URS Corporation <br />7650 Corporate Center Drive, Suite 400 <br />Miami, FL 33126 <br />POLICY NUMBER <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 />The Workers' Compensation coverage shown does not apply in monopolistic states. In the Statesof ND, OH, WA and WY Workers Compensation coverage is provided by the Stale Fund. In arose States, the above - <br />referenced policies provide Stop -Gap Employers Liability only. Workers Compensation p0cies apply as indicated below: <br />Insurer A: National Union Fire Ins Co Pittsburgh, PA NAIC# 19445100 <br />WC 021417576 - CA <br />Insurer D: Insurance Company Or The Slate Of PA NAIC #19429100 <br />WC 021417580 . MA, WI (Stop Gap - ND, OH, WA, WY) <br />WC 021417581 - AK, AL, AR, AZ, CO. 0E. GA, ID, KS, KY, M0, ME, MO, MS. MT, NC, NH, NM. NV, OK, OR, PA, RI, SC, SO, TN, UT, VA, VT, WV <br />WC 021417585 - MN <br />WC 021417578 -NY <br />Insurer C: Illinois National Ins Oo NAIC #23617001 <br />WC 021417577 -FL <br />WC 021417582 - CT, OC, HI, IA, IL. IN, IA, MI. NE. NJ <br />WC 021417579 - TX <br />ACORO 101 (2008101) 02008 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />UM Section 1— COMPANY INFORMATION 6 <br />