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AGENCY CUSTOMER ID: 00024288 <br />LOC #: <br />ADDITIONAL REMARKS SCHEDULE Page of <br />AGENCY <br />Insurance Brokers of MD - Hagerstown <br />NAMED INSURED <br />POLICY NUMBER <br />CARRIER <br />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: Notes <br />Forms provided: <br />GL-SS0008(04/05) - Includes-AI/Ongoing/Prod/Comp Ops, Waiver, PNC <br />Auto - HA9916 (12/21) - AI/PNC/Waiver <br />WC040306 - CA Waiver <br />ACORD 101 (2008/01) © 2008ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />