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AGENCY CUSTOMER ID: <br /> LOC#: <br /> Acoizo ADDITIONAL REMARKS SCHEDULE Page of <br /> AGENCY NAMED INSURED <br /> Arthur J. Gallagher Risk Management Services, Inc. <br /> A.C. Pavement Striping Co., Inc. <br /> I <br /> POLICY NUMBER 695 Church Road <br /> CARRIER NAICCODE Elgin, IL 60123 <br /> EFFECTIVE DATE: <br /> ADDITIONAL REMARKS <br /> THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br /> FORM NUMBER: FORM TITLE: <br /> GENERAL LIABILITY: <br /> Blanket Additional Insured coverage applies where required by written contract per <br /> Form #G17957 G99 10/01 <br /> Blanket Waiver of Subrogation coverage applies where required by written contract per <br /> Form #G186521 07/09 <br /> Primary and Non-Contributory coverage applies where required by written contract per <br /> Form #G186521 07/09 <br /> AUTOMOBILE LIABILITY: <br /> Blanket Additional Insured coverage applies where required by written contract per <br /> Form #CA 20 48 02 09 <br /> Blanket Waiver of Subrogation Coverage applies where required by written contract per <br /> Form #CA0444 03/10 <br /> WORKERS COMPENSATION: <br /> Blanket Waiver of Subrogation coverage applies where required by written contract per <br /> Form #WC000313 04/84 <br /> ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br /> it <br />