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DocuSign Envelope ID: F772F57D-CDB6-49D8-AED6-68B334B4C6C6 <br /> AGENCY CUSTOMER ID: <br /> LOC#: <br /> ,n`oRo ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br /> AGENCY NAMED INSURED <br /> Willis of Tennessee, Inc. DBA Willis of South Carolina Bonitz Flooring Group, Inc. <br /> 10701 World Trade Blvd <br /> POLICY NUMBER Raleigh, NC 27617 <br /> See Page 1 <br /> CARRIER NAIC CODE <br /> See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 <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 /> INSURER AFFORDING COVERAGE: Columbia Casualty Company NAIC#: 31127 <br /> POLICY NUMBER: CEO 1014136604 EFF DATE: 04/01/2019 EXP DATE: 04/01/2020 <br /> TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br /> Professional Liability Per Claim $2,000,000 <br /> Aggregate $2,000,000 <br /> Retention $ 50,000 <br /> INSURER AFFORDING COVERAGE: Travelers Property Casualty Company of America NAIC#: 25674 <br /> POLICY NUMBER: Y-630-OD492820-TIL-19 EFF DATE: 04/01/2019 EXP DATE: 04/01/2020 <br /> TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br /> Blk Bldg, BPP, Stock, Inv Total Values $32,035,000 <br /> Special Form <br /> Replacement Cost <br /> INSURER AFFORDING COVERAGE: Travelers Property Casualty Company of America NAIC#: 25674 <br /> POLICY NUMBER: QT-660-819OA917-TIL-19 EFF DATE: 04/01/2019 EXP DATE: 04/01/2020 <br /> TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br /> Contractors Equipment Owned Equipment $662,707 <br /> Boom & Jib Coverage Included Leased & Rented Equip $300,000 <br /> Overload excluded $5,000 Deductible <br /> ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br /> SR ID: 17675254 BATCH: 1122573 CERT: W10560886 <br />