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DocuSign Envelope ID:07A4359F-6D47-4987-B1F1-BF667ACBB3BA <br /> AGENCY CUSTOMER ID: MOFFPIP-01 <br /> LOC#: <br /> AC"R o ADDITIONAL REMARKS SCHEDULE Page 1 of 1 <br /> AGENCY NAMED INSURED <br /> Jones Insurance Agency, Inc. Moffat Pipe, Inc. <br /> 701 Finger Lakes Drive <br /> POLICY NUMBER Wake Forest NC 27587 <br /> CARRIER NAIC CODE <br /> EFFECTIVE DATE: <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 /> -The Workers Compensation policy includes 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 /> -Umbrella is follow form and extends over listed liability policies. <br /> -Executive Officers Andrea Moffat; Keith Moffat;and Craig Moffat are excluded from Workers Compensation. <br /> -Railroad Liability exclusion/limitation has been removed from the General Liability and Umbrella Liability. <br /> Orange County Solid Waste Drainage Repairs <br /> 1514 Eubanks Road,Orange County NC <br /> ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />