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EFFECTIVE DATE: <br />NAMED INSURED <br />POLICY NUMBER <br />NAIC CODECARRIER <br />AGENCY <br />LOC #: <br />AGENCY CUSTOMER ID: <br />ofPageADDITIONAL REMARKS SCHEDULE <br />ADDITIONAL REMARKS <br />FORM TITLE:FORM NUMBER: <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />© 2008 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />ACORD 101 (2008/01) <br />2 3 <br />Blue Lagoon Insurance Services LLC BCG Water, LLC. <br />4225 Solano Ave <br />#694 <br />Napa, CA, 94558-1611 <br />25 CERTIFICATE OF LIABILITY INSURANCE <br />Certificate holder is additional insured with respect to the General Liability insurance on a blanket basis per the attached endorsement subject to <br />the policy terms when required by written contract. A waiver of subrogation applies with respect to the General Liability and Workers Compensation <br />insurance on a blanket basis per the attached endorsement subject to the policy terms when required by written contract. 30 Day Notice of Cancellation <br />Applies. <br />Docusign Envelope ID: 475A1271-5695-469B-9AA9-36C5437FA957