Orange County NC Website
OP ID: CH <br /> CERTIFICATE OF LIABILITY INSURANCE F (MM/DD/YYYY) <br /> o7116112 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SI AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement A statement:on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement <br /> ONT <br /> PRODUCER 910-455-7576 C ACT <br /> NAME: <br /> SIA Group <br /> 827 Gum Branch Rd. 910-455-7481 (PAHICONE FAX <br /> .No.Ext): (A/C,No): <br /> Jacksonville,NC 28540M00 E-MAIL <br /> Bradley Carroll-SIA assigned ADDRESS: <br /> PRODUCER <br /> cusTomERID*.RECRE-3 <br /> INSURERS)AFFORDING COVERAGE NAIC <br /> INSURED Recreation Factory Partners, INSURER A:National Casualty <br /> LLC DBA Triangle Sports Plex INSURER 8:Carolina Mutual Ins.Co. 14090 <br /> 101 Meadowlands Drive <br /> Hillsbourough,NC 27278 INSURER C:Travelers 19070 <br /> INSURER D: <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> IC <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE ADDL SUBIR POLICY EFF POLICY XP <br /> LTR INISR-Wa POLICY NUMBER (MM)DONYYY) (MMIDDNM) LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0001 <br /> A X COMMERCIAL GENERAL LIABILITY X KK00000001463800 12(15111 12115/12 PREMISES Ee occurrence) $ 300,001 <br /> CLAIMS-MADE F—v-1 <br /> I OCCUR MED EXP(My one person) $ 5,00q <br /> PERSONAL&ADV INJURY $ 1,000,001 <br /> GENERAL AGGREGATE $ non( <br /> GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 C <br /> I POLICYF—]JERCof F]LOC Emp Ben. $ 1,000,00C <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> C X ANYAUTO BA-3423PI16-11-SEL 12JI9111 12/19/12 (Ea accident) $ 1,000,00C <br /> BODILY INJURY(Perperson) $ <br /> ALL OWNED AUTOS BODILY INJURY(Per accident) $ <br /> SCHEDULED AUTOS PROPERTY DAMAGE <br /> HIRED AUTOS (Per accident) $ <br /> NON-OWNED AUTOS $ <br /> F1 $ <br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 <br /> A EXCESS LIAR CLAIMS-MADE XK00000001 464000 12J15111 12/15/12 AGGREGATE $ <br /> DEDUCTIBLE $ <br /> X RETENTION $ 0 $ <br /> WORKERS COMPENSATION X WC ST <br /> AND EMPLOYERS'LIABILITY YIN TORY ER <br /> B ANY PROPRIETOR/PARTNERfExECUTIVE WC161602011 12(28111 12/28(12 E.L.EACH ACCIDENT $ 1,0()0,000 <br /> OFFICERIMEMBER EXCLUDED? ❑ NIA <br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 <br /> If yes,desonbe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (Attach ACORD 101,Additional Remarks Schedule,ifmoro space Is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORANG09 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> PO BOX <br /> ORANGE COUNTY ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 8181 <br /> Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE <br /> 071988-2009 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD <br /> I I - <br />