LEGAL SHIELD (PRE-PAID LEGAL SERVICES, INC )

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AGENCY CUSTOMER ID: PRE-LEG-01 _ LOC#: AR ADDITIONAL ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Higginbotham Insurance Agency,Inc. Pre-Paid Legal Services, Inc.dba LegalShield **complete list of named insureds below POLICY NUMBER 1 Prepaid Way Ada OK 74820 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Pre-Paid Canadian Holdings, LLC PPL Legal Care of Canada Corporation Workers Compensation Policy-7182-73-92 All States except IA,IN, MD,MS ND,NV OH,PA,WA,WY and those states listed in 3A(3A consists of AR AZ CA CO CT FL GA HI IL MA MI MO NJ NY OK PA RI TN TX UT The General Liability Additional insured includes From 80-02-2367(5-07)Persons or organizations that you are obligated,pursuant to a contract or agreement, to provide with such insurance as is afforded by this policy. The Automobile Additional Insured includes form(CA 20 48)Persons or organizations that you are obligated, pursuant to a contract or agreement between you and such person or organization,to provide with such insurance as is afforded by this policy. However,no such person or organization is an insured under this provision who is more specifically described under any other provision of the"Who Is An Insured"section of this policy(regardless of any limitation applicable thereto)or who is a branch,department,agency,corporation or other governmental authority of the Federal Government of the United States of America. The General Liability Waiver of Subrogation includes form(80-02-2000)provides a blanket waiver of subrogation endorsement when required by written contract. The Automobile Liability Transfer of Right of Recovery against others to us under Loss Conditions. Workers Compensation waiver of Subrogation includes Any person or organization against whom you have agreed to waive your right of recovery in a written contract,provided such contract was executed prior to the date of loss. The General Liability has a blanket Primary&Non Contributory endorsement that affords that coverage to certificate holders only where there is a written contract 80-02-2367(5-07). The Automobile Primary&Non Contributory included form(16-02-0316)Persons or organizations that you are obligated,pursuant to a contract or agreement between you and such person or organization,to provide primary and non-contributory insurance. The General Liability(80-02-9779)Automobile Liability(16-02-0306) If you are obligated,pursuant to a written contract or agreement,to provide persons or organizations with Notice of cancellation,then we will notify such persons or organizations provided that within 15 days of the date we send Notice of Cancellation to the first named insured,the first named insured or producer of record provides us with a spreadsheet containing the name,mailing address and, if available,e-mail address of the persons or organizations. Excess Liability is follow form. Certificate holder is complete to include: City of Santa Ana / Risk Managemerd Division ; \ REVIEWED/&APPROVED BY: `I, its: 1'� f1' 11cw ®, Risk Management Specialist ACORD 101 (2008/01) ©2008 ACORD I/ The ACORD name and logo are registered marks of ACORD