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AGENCY CUSTOMER ID: <br /> LOC#: <br /> s4C'�a <br /> ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br /> AGENCY NAMED INSURED <br /> HUB INTL MOUNTAIN STATES LTD/PHS MARTHA VAN ROOIJEN DBA MVR CONSULTING <br /> POLICY NUMBER PO BOX 236 <br /> SEE ACORD 25 CALIMESA CA 92320-0236 <br /> CARRIER NAIC CODE <br /> SEE ACORD 25 <br /> EFFECTIVE DATE:SEE ACORD 25 <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM <br /> FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br /> Notice of Cancellation will be provided in accordance with Form SS1223, attached to this policy. Waiver of Subrogation applies <br /> in favor of the Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy. Certificate holder is <br /> an additional insured per the Business Liability Coverage Form SS0008, attached to this policy. Certificate holder is an <br /> additional insured per the Business Liability Coverage Form SS0008 and the Hired Auto and Non Owned Auto Endorsement <br /> SS0438, attached to this policy. <br /> IN <br /> Risk ManagemenEDtviston <br /> REVIEWED&APPROVED BY: <br /> imasimit <br /> Risk Management Specialist <br /> ACORD 101 (2014/01) ©2014 ACORD CORPOft. <br /> The ACORD name and logo are registered marks of ACORD <br />