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AGENCY CUSTOMER ID; <br />LOC #; <br />* r ~ ` ADDITIONAL SCHEDULE <br />AGENCY <br />NAMED INSURED <br />Willis of Tennessee, Inc. <br />Peabody Baergy Corporation <br />701 market Street <br />Suite 700 <br />POLICY NUMBER <br />See Page 1 <br />St. Louis, MO 631011826 <br />CARRIER <br />NAIC CODE <br />See Page 1 <br />See Page 1 <br />EFFECTIVE DATE! See Page 1 <br />5115 019 1117X10--iYllLIi1il�: <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: .. 25 FORM TITLE: Certificate of Liability Insurance <br />the use of explosives. <br />ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />SR lot 14983031 —1 476354 CERT: W3331000 <br />