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ADDITIONAL INTEREST SCHEDULE DATE (MM/DD/YYYY) <br />02/28/2023 <br />AGENCY CARRIER <br />Great American Insurance Company <br />NAIC CODE <br />16691 <br />POLICY NUMBER <br />GAP108229/PAC 4725034 <br />EFFECTIVE DATE <br />04/01/2023 <br />12:00 AM <br />NAMED INSURED(S) <br />Tiger PaSaRyu Martial Arts DBA Nishith Trivedi <br />ADDITIONAL INTEREST (Not all fields apply to all scenarios – provide only the necessary data) <br />Page 1 of 1 <br />ACORD 45 (2009/04)© 1993-2009 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />INTEREST NAME AND ADDRESS RANK:EVIDENCE:CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER <br />X ADDITIONAL <br />INSURED LOSS PAYEE LOCATION:BUILDING: <br />BEACH OF <br />WARRANTY MORTGAGEE VEHICLE:BOAT: <br />CO-OWNER OWNER AIRPORT:AIRCRAFT: <br />EMPLOYEE <br />AS LESSOR REGISTRANT ITEM <br />CLASS:ITEM: <br />LEASEBACK <br />OWNER TRUSTEE <br />Orange County, NC  <br />PO Box 8181  <br />Hillsborogh, NC 27278 <br />ITEM DESCRIPTION <br />LIENHOLDER REFERENCE / LOAN #:INTEREST END DATE: <br />LIEN AMOUNT:PHONE (A/C, No, Ex):FAX (A/C, No): <br />REASON FOR INTEREST:E-MAIL ADDRESS: <br />The above are added as additional insured but only with respect to liability arising out of operations of the named insured during the policy period. <br />DocuSign Envelope ID: 5E4EB900-3E1E-4A3B-B716-0F8CC94B1C47