Orange County NC Website
Browse       Search
ACORD 101 (2008/01) <br />The ACORD name and logo are registered marks of ACORD <br />© 2008 ACORD CORPORATION. All rights reserved. <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER:FORM TITLE: <br />ADDITIONAL REMARKS <br />ADDITIONAL REMARKS SCHEDULE Page of <br />AGENCY CUSTOMER ID: <br />LOC #: <br />AGENCY <br />CARRIER NAIC CODE <br />POLICY NUMBER <br />NAMED INSURED <br />EFFECTIVE DATE: <br />QSHACKU-01 <br />1 1 <br />Jones Insurance Agency,Inc.The Q Shack Unlimited Corporation <br />4205 Branchwood Drive <br />Durham NC 27705 <br />25 CERTIFICATE OF LIABILITY INSURANCE <br />•The Workers Compensation policy includes a waiver of subrogation endorsement that provides waiver of subrogation status to the certificate holder and other <br />entities when there is a written “insured contract”between named insured and certificate holder that requires such status. <br />DocuSign Envelope ID: 46AAA209-37F8-4264-B691-2868C8B31BDA