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DocuSign Envelope ID: 3DA3CD72-390C-4765-969A-9FC5040C04E7 <br /> AGENCY CUSTOMER ID: NWPOOLE-01 <br /> _ LOC#: <br /> AC o ADDITIONAL REMARKS SCHEDULE Page 1 of 1 <br /> AGENCY NAMED INSURED <br /> Jones Insurance Agency Inc. Letco Inc dba N W Poole Well& Pump Co <br /> P.O. Box 1958 <br /> POLICY NUMBER Wendell NC 27591 <br /> CARRIER NAIC CODE <br /> EFFECTIVE DATE: <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br /> FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br /> subrogation endorsement that provides waiver of subrogation status to the certificate holder and other entities when there is a written"insured <br /> contract"between named insured and certificate holder that requires such status. <br /> •The Workers Compensation policy includes a blanket waiver of subrogation endorsement that provides waiver of subrogation status to the <br /> certificate holder and other entities when there is a written"insured contract"between named insured and certificate holder that requires such <br /> status. <br /> • Umbrella is follow form and extends over listed liability policies. <br /> ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />