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AGENCY CUSTOMER ID: <br />LOC #: <br />Page ofADDITIONAL REMARKS SCHEDULE <br />AGENCY NAMED INSURED <br />POLICY NUMBER <br />CARRIER NAIC CODE <br />EFFECTIVE DATE: <br />ADDITIONAL REMARKS <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER:FORM TITLE: <br />ACORD 101 (2008/01)© 2008 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />QUALAIR-01EWELLL <br />1 <br />11 <br />License # 0E67768 <br />Quality Air Tool Repair, Inc. <br />1460 W. Evans St. <br />Florence, SC 29501 <br />Insurance Office of America, Inc. <br />SEE PAGE 1 <br />SEE PAGE 1SEE P 1 SEE PAGE 1 <br />ACORD 25Certificate of Liability Insurance <br />Description of Operations/Locations/Vehicles: <br />Automobile Liability-Forms & Endorsments <br />Blanket Additional Insured per carrier form 16-02-0292 (04/11) <br />Waiver of Subrogation per carrier form 16-02-0292 (04/11) <br />Workers' Compensation-Forms & Endorsements <br />Blanket Waiver of Subrogation per form WC 00 0313 (04/84) <br />Excess/Umbrella Following Form - Coverage A per form 07-02-0815 (07/01) <br />DocuSign Envelope ID: 6CE9F4FB-27D4-4B9A-A269-DDC1952921CB