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<br /> DocuSign Envelope ID:6DC1 ED22-13276-4193-131 F9-548B6AFFC7C5
<br /> AGENCY CUSTOMER ID:
<br /> LOC#:
<br /> A��0 ADDITIONAL REMARKS SCHEDULE Page 1 Of 1
<br /> AGENCY OI�NO2saElns�rdncgggancy NAMED INSURER
<br /> .Carrboro.NC 2751C
<br /> POLICY NUMBER Empowerment Inc
<br /> CPS3189063 109 N Graham St #200
<br /> CARRIER Chapel Hill NC 27516
<br /> Scottsdale Insurance Company NAIC CODE
<br /> 141297 EFFEcrIVI DATE:06/16/2019
<br /> ADDITIONAL REMARKS
<br /> THIS ADDrr1ONAL REMARKS FORM IS A SCHEDULE TO ACQRD FORM,
<br /> FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
<br /> LQC: 800 Pritchard Ave Ext F9, Chapel Hill, NC 27516; 800 Pritchard Ave Ext ❑18, 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 Hilt, NC 27516; 501 Jones Ferry Road P-8, Carrboro, NC 27510; 501 Jones Ferry Road E-8,
<br /> Carrboro, NC 27510; 501 Jones 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 27516 / DED: $2,500.00 / CO-
<br /> INS: 80% I RC BASIS. Certificate holder is listed as Additional Insured per form CG201❑ (4113).
<br /> ACQRD 101 (2008101) 02008 ACQRD CORPORATION. All rights reserved_
<br /> The ACQRD name and logo are registered marks of ACQRD
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