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AGENCY CUSTOMER ID: 57D000007117 <br />LOC #: <br />4COR[a Ann ITI A AI AI tlCffim mw +• n. Llu my Pr <br />mar vi t 1%j`1VMV nGIV1Mnn.7 .7Vf7GLJULC Page _ of <br />[ieNLY AAPLU X.nV RPn <br />Ion Risk Insurance Services West, Inc. Axon enterprise, Inc. <br />,ee (PItificate Nuluher: 57008428782G <br />IAnP 1--: nA6 u:0a <br />lee Cer L;ricare Number: 570084287826 <br />=e=�.ma uAlc <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACOR0 25 FORM TITLE: Carkhoale of Uatnifty insurance <br />Par Li Ciparing WC/E'_ Insurance Cuiopanies <br />-hrin City Tire ins. Co. [AL, CO, rL, 1L, is, LA, ME, MI, MN, MU, NO, NE, NH, NM, NV, OH, 111, PA 'WAf <br />-Hartford Undervri Lers Lns. Co. [AR, DC, CA, M0, NC, A:I, NY, OR. TN, UT] <br />-Property 6 casualty Ins. Co of Hartford [Nn, vAJ <br />-Hartford Insurance Company of the Midwest LCTJ <br />-Hartford Accident and indemnity Insurance Company [MA] <br />-Hartford I.lnyds Ins. Co. [T%] <br />-Sentinel Ins. Co. [CA] <br />+« RlakMamgensaltD[sAelan <br />[ <br />AW1101011bnA01) t=,WOO ACORO CORPOHanrM,- <br />Rkvle 6APPRCIV®RY: <br />r h <br />Risk Management Anaysr <br />rng ACURD name and W90 are rnglsr0md marks of ACORn <br />