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AGENCY CUSTOMER ID: <br /> LOC#: <br /> ADDITIONAL REMARKS SCHEDULE Page 2 of 2 <br /> AGENCY NAMED INSURED <br /> BURNETTE INSURANCE AGENCY INC/PHS THE ADR COACH, INC., ANGELA D SHAW DBA THE ADR <br /> POLICY NUMBER COACH <br /> SEE ACORD 25 3782 WELLINGTON RD <br /> CARRIER NAIC CODE LOS ANGELES CA 90016-5859 <br /> SEE ACORD 25 EFFECTIVE DATE:SEE ACORD 25 <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM <br /> FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br /> Notice of Cancellation will be provided in accordance with Form SL9013, attached to this policy. Waiver of Subrogation applies <br /> in favor of the Certificate Holder per the Business Liability Coverage Form SL 00 00, attached to this policy. Coverage is <br /> primary and noncontributory per the Business Liability Coverage Form SL 00 00, attached to this policy. The Business Liability <br /> Coverage Part includes a Blanket Additional Insured By Contract Endorsement, Form SL 30 32. <br /> ACORD 101 (2014/01) ©2014 ACORD CORPORATION.All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />