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DocuSign Envelope ID:CFAC8B75-13DE-422C-B3F4-DEE7176415C2 <br /> AGENCY CUSTOMER ID: <br /> LOC#: <br /> AC"J?o ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br /> AGENCY NAMED INSURED <br /> Willis Towers Watson Southeast, Inc. Lamar Advertising Company & all subsidiaries <br /> PO Box 66338 <br /> POLICY NUMBER Baton Rouge, LA 70896 <br /> See Page 1 <br /> CARRIER NAIC CODE <br /> See Page 1 See Page 1 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 /> Re: Billboard Advert in Hillsborough, NC <br /> Certificate Holder is included as Additional Insured under General Liability as required by written contract. <br /> INSURER AFFORDING COVERAGE: AIU Insurance Company NAIC#: 19399 <br /> POLICY NUMBER: WC058240120 EFF DATE: 01/01/2021 EXP DATE: 01/01/2022 <br /> TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br /> Workers Compensation/ E.L. Each Accident $1,000,000 <br /> Employers Liability - (CA) E.L. Disease-Ea Empl $1,000,000 <br /> Per Statute E.L. Disease-Pol Lmt $1,000,000 <br /> INSURER AFFORDING COVERAGE: New Hampshire Insurance Company NAIC#: 23841 <br /> POLICY NUMBER: WC058240122 EFF DATE: 01/01/2021 EXP DATE: 01/01/2022 <br /> TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: <br /> Workers Compensation/ E.L. Each Accident $1,000,000 <br /> Employers Liability-(MA,ND,OH,WA,WI, E.L. Disease-Ea Empl $1,000,000 <br /> WY)Per Statute E.L. Disease-Pol Lmt $1,000,000 <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: 20518529 BATCH: 1927812 CERT: W19551627 <br />