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DocuSign Envelope ID: CD64977C-17FD-49F0-9672-81 06326AF370 <br />AGENCY CUSTOMER ID: ___________________ _ <br />_,............ ® <br />I,,_....--· <br />LOC II:--�----- <br />ADDlllONAl IAEMAIAKS SCHEDUlE <br />AGENCY ·NAMED INSURED LLC <br />POLICY NUMBER Seo Paga 1 IL USA <br />CARRIER I NAIC CODE Pogo 1 S12a Paga ·1 EFFECTIVE DATE: Sao l?ago 1 <br />ADDITIONAL REMABl<S <br />THIS ADDITIONAL REMARl<S FORM IS A SCHEDULE TD ACORD FORM, <br />FORM NUMBER: <br />Page 2 of 2 <br />ACORD 101 (200B/0 1) ©2008 ACORD CORPORATION, All rights reserved. <br />The ACORD name and logo are registered marks of.ACORD <br />BATCH : 928392 CERT : W8655692 <br />Docusign Envelope ID: 30116525-3CA0-44BF-A300-567E64354BC7