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AGENCY CUSTOMER ID: <br />LOC #: <br />AC"R" ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 2 <br />AGENCY <br />NAMED INSURED <br />Willis Towers Watson Midwest, Inc. <br />Centerra Group, LLC <br />13530 Dulles Technology Drive <br />Suite 500 <br />POLICY NUMBER <br />See Page 1 <br />Herndon, VA 20171 <br />CARRIER <br />NAIC CODE <br />See Page 1 <br />See Page 1 <br />EFFECTIVEDATE: See Page 1 <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance <br />INSURER AFFORDING COVERAGE: Starr Indemnity 6 Liability Company <br />POLICY NUMBER: 100 0001595 EFF DATE: 11/01/2021 EXP DATE: 11/01/2022 <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Workers Compensation a E.L. Each Accident: $1,000,000 <br />Employers Liability E.L. Disease Ea. Emp: $1,000,000 <br />Per Statute E.L. Disease-Pol Lmt: $1,000,000 <br />INSURER AFFORDING COVERAGE: Starr Indemnity 6 Liability Company <br />POLICY NUMBER: 100 0004398 EFF DATE: 11/01/2021 EXP DATE: 11/01/2022 <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Workers Compensation 6 E.L. Each Accident: $1,000,000 <br />Employers Liability E.L. Disease -Ea Empl: $1,000,000 <br />Per Statue E.L. Disease-Pol Lmt: $1,000,000 <br />INSURER AFFORDING COVERAGE: Starr Indemnity 6 Liability Company <br />POLICY NUMBER: 100 0003048 EFF DATE: 11/01/2021 EXP DATE: 11/01/2022 <br />TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br />Workers Compensation 6 E.L. Each Accident: $1,000,000 <br />Employers Liability E.L. Disease -Ea Empl: $1,000,000 <br />Per Statue E.L. Disease-Pol Lmt: $1,000,000 <br />ACORD 101 (2008101) © 2008 ACORD <br />The ACORD name and logo are registered marks of ACORD <br />SR ID: 23018874 BATCH: 2655969 CERT: W25793937 <br />NAIC#: 38318 <br />NAICN: 36318 <br />NAIC#: 38318 <br />wrnwegmWr¢uovon <br />REVIEWEDSAPPROVEDBY: <br />T4" Jk4 <br />® Risk Management Analyst <br />