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DocuSign Envelope ID: F396A7D5-62F3-4B5B-A968-F49AA5397EFF
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<br /> AGENCY CUSTOMER ID:
<br /> LOC#:
<br /> A a o® ADDITIONAL REMARKS SCHEDULE Page 1 of
<br /> AGENCYCarNina National Insurance Agency NAMED INSURED
<br /> PO Box ion
<br /> Carrboro NC2751D
<br /> POLICY NUMBER Empowerment Inc
<br /> CP53189063 109 N Graham St #200
<br /> Chapel Hill NC 27516
<br /> CARRIER NAIL co DE
<br /> Scottsdale Insurance Company 41297 EFFECTIVE DATE:06/16/2019
<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 /> LCC: 800 Pritchard Ave Ext F9, Chapel Hill, NC 27516; 800 Pritchard Ave Ext D18, Chapel Hill, NC
<br /> 27516; 800 Pritchard Ave Ext A18, Chapel Hill, NC 27516; 707 Gomains Ave, Chapel Hill, NC 27516; 613
<br /> Sykes St., Chapel Hill, NC 27516; 608 Bynum St., Chapel Hill, NC 27516; 606 Bynum St., Chapel Hill, NC
<br /> 27516; 509 Pritchard Ave, Chapel Hill, NC 27516; 507 Terrell Rd., Hillsborough, NC 27278; 505 Edwards
<br /> Drive, Chapel Hill, NC 27516; 501 Jones Ferry Road P-8, Carrboro, NC 27510; 501 Jones Ferry Road E-8,
<br /> Carrboro, NC 27510; 501 Janes Ferry Road E-4, Carrboro, NC 27510; 405 Sykes St., Chapel Hill, NC
<br /> 27516; 338 McMasters St., Chapel Hill, NC 27516; 320 McMasters St., Chapel Hill, NC 27516; 316
<br /> McMasters St. A& B, Chapel Hill, NC 27516; 2308 Redbird Lane, Hillsborough, NC 27278; 227 N.
<br /> Graham St., Chapel Hill, NC 27516; 225 N. Graham St., Chapel Hill, NC 27516; 221 N. Graham St.,
<br /> Chapel Hill, NC 27516; 219 N. Roberson St., Chapel Hill, NC 27516; 216 Knolls St., Chapel Hill, NC
<br /> 27516; 128 Johnson St., Chapel Hill, NC 27516; 122 Johnson St., Chapel Hill, NC 27516; 113 Asheley
<br /> Forest Road, Chapel Hill, NC 27514; 109 N. Graham St,, Chapel Hill, NC 275161 DED: $2,500.001 CO-
<br /> INS: 80% I RC BASIS
<br /> ACORD 1 D1 (2008101) ©2008 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
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