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AGENCY CUSTOMER ID: 00106559 <br />LOC #: <br />ADDITIONAL REMARKS SCHEDULE Page of <br />AGENCY <br />North Risk Partners <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 <br />Kentucky where prohibited by law utilizing the following policy forms: California WC 99 03 04, Texas WC 42 03 04, All Other States, Except Kentucky WC <br />00 03 13, when required by prior written agreement. Workers' Compensation coverage is not provided in the following monopolistic states: ND; OH, WA; <br />and WY. <br />ACORD 101 (2008/01) © 2008ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />