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a <br />AGENCY CUSTOMER ID: <br />LOC #: <br />A o ADDITIONAL REMARKS SCHEDULE <br />Page 2 of 3 <br />AGENCY NAMED INSURED: SPECIAL LIABILITY INSURANCE PROGRAM (SLIP) MEMBER: <br />ALLIANT INSURANCE SERVICES, INC. <br /> PAINT YOUR HEART OUT, INC. <br />POLICY NUMBER 1260 N. HANCOCK, UNIT 103 <br />PAC 1000001 00 ANAHEIM, CA 92807 <br />CARRIER NAIC CODE <br /> <br />ASSOCIATED INDUSTRIES INSURANCE CO. 23140 <br />EFFECTIVE DATE: 09/29/11 <br />ADDITIONAL REMARKS <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 (2009/09) FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />Notice of cancellation will be delivered only to the participating named insured as stated in Item 1 of the <br />Participation Endorsement. <br />The Company may cancel the coverage by mailing to the first Participating Named Insured at the address shown in the participation <br />endorsement written notice stating when, not less than sixty (60) days thereafter, such cancellation shall be effective. Provided that the <br />Participating Named Insured fails to discharge, when due, any of its obligations in connection with the payment of premium for the policy or <br />any installment thereof, the coverage may be canceled by the Company by mailing to the Participating Named Insured at the address <br />shown in the participation endorsement, written notice stating when, not less than ten (10) days thereafter, such cancellation shall be <br />effective. <br />pgpS®VED AS TO FORD <br />E gTORCK <br />pss? tat cm Attorney <br />3