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Docusign Envelope ID:C101DF94-8EEA-4210-A163-1FB71C9DF46C <br /> AGENCY CUSTOMER ID: CLUBLLC-01 <br /> LOC#: <br /> AC"J?o ADDITIONAL REMARKS SCHEDULE Page 1 of 1 <br /> AGENCY NAMED INSURED <br /> Arthur J.Gallagher Risk Management Services, LLC RecTrac,LLC dba Vermont Systems <br /> 12 Market Place <br /> POLICY NUMBER Essex Jct,VT 05452 <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 /> -Additional Insured by Contract,Agreement or Permit when required in a written contract with you; <br /> -Waiver of Subrogation when required in a written contract with you <br /> The client does not have any owned/titled vehicles at this time. <br /> BA: CNA83700XX(10/2015)Extended Coverage-BA Plus-For Hired and Non-Owned Autos which provides the following: <br /> -Additional Insureds Required by Written Contracts <br /> -Employee-Hired Autos <br /> -Waiver of Subrogation <br /> -Primary and Non-Contributory When Required By Contract <br /> BA:CA0444(10/13)Business Auto-Waiver of Transfer of Rights of Recovery Against Others to Us(Waiver of Subrogation).Blanket when required by contract <br /> with you. <br /> WC:WC000313(04/84)Blanket Waiver of Subrogation when required in a written contract with you where allowed by State law. <br /> WC:WC420304B(06/14)Texas Blanket Waiver of Subrogation when required in a written contract with you. <br /> WC:WC430305(07/00)Utah Blanket Waiver of Subrogation when required in a written contract with you. <br /> WC:G19160B(11/97)California Blanket Waiver of Subrogation when required in a written contract with you. <br /> Umbrella is follow form regarding underlying: CGL BA WC <br /> Prof/Cyber Retention: $300,000; Retro Active 3/23/11 <br /> Prof/Cyber:GSL2302XX(06/11)CNA EPS+Technology E&O,Cyber and Multimedia Liability Insurance Policy coverage form: <br /> -pg 3 Automatic Additional Insured status when required by written contract with you; <br /> Prof/Cyber:CNA71810XX(11/12)Automatic Waiver of Subrogation where required by written contract with you. <br /> Third Party Crime Deductible: $25,000 <br /> Orange County,its officers,agents and employees are shown as additional insureds solely with respect to General Liability policy as required by written contract. <br /> Workers'compensation waiver of subrogation applies in favor of certificate holder. <br /> ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />