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AGENCY CUSTOMER ID: 570000082030 <br />LOC #: <br />ADDITIONAL REMARKS SCHEDULE <br />Page _ of _ <br />AGENCY <br />AOn Risk Services Central, Inc. <br />NAMEDINSURED <br />Burke, Williams & Sorensen, LLP <br />POLICY NUMBER <br />See Certificate Number: 570087555922 <br />CARRIER <br />See Certificate Number: 570087555922 <br />NAIC CODE <br />EFFECTNE DATE: <br />THIS ADDITIONAL REMARKS FORM IS ASCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liabilitv Insurance <br />INSURER(S) AFFORDING COVERAGE I NAIC # <br />ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD <br />certificate form for policy limits. <br />BVSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUER <br />WVD <br />POLICY NUMBER <br />POLICY <br />EFFECTIVE <br />DATE <br />(MM/DD(YYYY) <br />POLICY <br />EEP UON <br />DATE <br />(MM/DD/(YYY) <br />LEMITS <br />OTHER <br />D <br />LPL7CABW3D1002 <br />01/15/2021 <br />01/15/2022 <br />ACORD 101 (2008101) <br />The ACORD name and [ago are registered marks of ACORD <br />©2008 ACORD e� EIek MWVg*n tVistilan <br />cREVIEWED& APPROVED Y <br />�ED RA: <br />'tIDLUJ1EL=� rMfA�GN�L Z Y+lrA44d <br />��' Risk Management Analyst <br />