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AGENCY CUSTOMER lD: W0129
<br />LOC #: fvfOrrlStOWrl
<br />Page 2 �Of.-.2
<br />AGENCY
<br />NAMED INSURED
<br />MAR ,"H Tj,3A N(:
<br />3VAENS INCuSrR,r Ac
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<br />POLICY NUMBER
<br />10(116 DEER l-.-,, PARK1h,"O'
<br />K,FFA�.o ,ROVE q- �30089
<br />CARRIER
<br />NAIL GC1aE
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<br />=VIEVIVE DATE
<br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
<br />FORM NUMBER: 25 FORM TITLE; Certificate of babiliky Insurance
<br />RE 91,%2Pf,,Y)7119G0 P093'2(rX)W5 PRQdEC T# W)(,'7C5�3 "R,0JE;17 NAW b(,'Ad 'SE'S C I 'Y QF SAW A ANA P(A ICE DEP F
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<br />RAC,,")NTRA(,'T()RS Ni 'If R ESP TO ALI- ()I'I:RATW)N3 ;IF THE NSuRK 310 ()NT,( WT'H RE',EP;:;1' LM_ NCiRK PFRF0 RMEF, BY AND ON BEHALF OF THE
<br />NAMED N.IJR,'F,-D 51EMEN,'; R" NU PUR CERMF ICA C:-' HOLDEq JN DER
<br />Jr." )WhIcR AND C ON 'RAC FCR NAIvEAi.I- AGA �NS' EACH W},ER AND AWfOTHEIR C'01,TTRACTOR 3USC ON I RA;',711RS SI)B-3U8C01N!'RAC7)R
<br />,(SEhjr3 ANC LWLOYEES IOR ")R N,4)R I ES (,A4SFD Be PF;jj_�S ro T,(E EXTENCuO(E REE, 9Y fWSURANCF, E,XCEPT 3')CH R!CHTS A", THEY MAY
<br />HA /F TU OF SI)CH INSW?ANCE HE,D BY THE OWNER, ASA RC]LICARY
<br />CUMPLE I ED OPERA -IONS tS INCILL)CED N TI IF GET,0:RAL uABIUTY PCAUCY
<br />IF TF, ESE `O[JCES ARE CMTfCEU ED -OR AN I REASON OTHER THAN 40", PA'MErV CF PREVIJM TI,E INSURER APT -i. DE PiER NOTNCOF _A Dtf rC,)
<br />TFE CER, 'IF CA HDJOEP uP rC,-)C DAYS F�5JCR TO TI E CAWTLi-ATV,OIA A3, PE -Eu ,R,ED RYWR I 7EN . jN T5VG Ir NMjAC_dpj;7p SLJSa
<br />ACORD 101 12008101) '� 2008 ACORD
<br />The ACORD name and logo are registered marks of ACORD
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