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AGENCY CUSTOMER IO <br />LOC #l <br />cN101642069 <br />Atlanta---\ "A,CC)RI)'ADDITIONAL REMARKS SCHEDULE Page 2 of 3 <br />ADOiTIONAL REMARKS <br />THIS ADOITIONAL REMARXS FORM IS A SCHEOULE TO ACORD FORM. <br />FORM NUMBERi <br />-?1- <br />rOnU nrle,Cenrficate of Liabilrty lnsurance <br />;arner .demnry nsu.aftre lompa.r )l |!cnn iren(a <br />Poxc,'rLrDer l,,i :6a-c2?:'a A! ri:! C A '(S,( <br />/ Lr VS \(] lE rri! \L l* :a SD r\ <br />^/, <br />lv <br />EnE{rve lare -r: l], 2C2, <br />Erorrtoi lae C:3 0' 2l]21 <br />rELrr-m 3t im lct <br />Camer iler Hen!6hrE ins!.ete Contoary <br />Porrcy [umD€r tlc 023C$m3 (CJC DEHI rrl ll0 ilN Ur NY Rll <br />Efecnve DaE 0301 20m <br />€tolabn oal8 03,01 2021 <br />lELrlm,r S5 0m 000 <br />Caner ACE Aflencan hsuGn e iomDany <br />PorEy r,Jumrer ',ta! a66922753 LQSI) raz :r LIC CR /a /lr , <br />:leclve !.eP l3C' 2C2C <br />E${raloi 06re a3 0' 2c21 <br />lELr LJrn I 54 000 oci <br />jrR 3! 000 C(S SIR ror he naes Dl Al :,r L fta OR # /ll <br />:aoer \aiora Jno.; re .surarEe:ohg*Jy <br />?rry rtumber {wc 45593$ oslr rcc:r f,r vE vl NY Jir ia JII <br />EfecNe laE 4301 2020 <br />Erriaioc Dae 03.C1 2C21 <br />ELrL,m[ S,l0(! JCC <br />51l000l[ SLR rorlta srales3l:0 UE n! Ul 0r. PA uI <br />5750 J00llR tor th€ lrae ol GA <br />S35l 100 SrR ,or fie nEEDI:T <br />Canar Naoo.d Jnon F e lnsu,anco CdntiJly <br />Poftr iilrnber IWC 6559357{OSD iUA) <br />Efectve DaE 0301 20m <br />ErfleEr' oale 03 01 z)21 <br />(EL) u,i 54 500 000 <br />srR s500 0m <br />Tx E ndoyeG xS ndenftrr <br />Camerllhros LJn6n h$ra,lce a,lnoaa, <br />Poi€y NumDer INS C66932315 lTx) <br />Enrove Dae 03'01 2020 <br />Elp.aon Dale $ 0r m21 <br />(€U Lrmi SI0m0000 <br />srR s1 000 000 <br />O 2008 ACORO CORPORATION. All .i9hts reserved. <br />The ACORO namo and logo are registered marks of ACORD <br />xALC CC0E <br />EFFECTIVE DA'E <br />ACORO r01 (2008/0J )