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OP ID:NE <br /> ,�coR°A CERTIFICATE OF LIABILITY INSURANCE DATE(M <br /> `—� 10/1155D/YYYY) <br /> /12 <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(S), 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(s). <br /> PRODUCER CONTACT <br /> High&Rubish Insurance Agency 919-913-1144 PHONE Fax <br /> P.O.Box 3040 919-913-1155 A/C No Ext: A/C No <br /> 6015 Farrington Rd.Ste 101 E-MAIL <br /> Chapel Hill,NC 27517 ADDRESS: <br /> Jeffre Y A.Rubish PRODUCER EMPOW-1 <br /> C STOMER ID Y: <br /> INSURER(S)AFFORDING COVERAGE NAIC A <br /> INSURED EmPOWERment,Inc. INSURER A:Owners Insurance Company 32700 <br /> 109 N Graham St.Ste 200 INSURERS: <br /> Chapel Hill,NC 27516 <br /> INSURER C: <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 /> 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 POLICY EFF LICY EXP LIMITS <br /> LTR POLICY NUMBER MM/DD/YYYY MM/DDIYYYY <br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 <br /> A X COMMERCIAL GENERAL LIABILITY X 4261010000 12/14/11 12/14112 PREMISES Ea occurrence $ 50,00 <br /> CLAIMS-MADE I—XI OCCUR MED EXP(Any one person) $ 5,00 <br /> PERSONAL&ADV INJURY $ 1,000,00 <br /> GENERAL AGGREGATE $ 2,000,00 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 <br /> POLICY PRO- LOC $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED AUTOS <br /> BODILY INJURY(Per accident) $ <br /> SCHEDULED AUTOS PROPERTY DAMAGE <br /> HIRED AUTOS (Per accident) $ <br /> NON-OWNED AUTOS $ <br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE $ <br /> EXCESSLUIB CLAIMS-MADE AGGREGATE $ <br /> DEDUCTIBLE $ <br /> RETENTION $ $ <br /> WORKERS COMPENSATION X WC STATU- TH- <br /> ITORY EMPLOYERS'LIABILITY LIMITS <br /> A ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A 35019565 03/16/12 03/16113 E.L.EACH ACCIDENT $ 500,00 <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 <br /> BUILDING 1,173,70 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) <br /> Additional Insured: Orange County <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORANG-1 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> ORANGE COUNTY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Risk Manager ACCORDANCE WITH THE POUCY PROVISIONS. <br /> P 0 Box 8181 <br /> HILLSBOROUGH,NC 27278 AUTHORIZED REPRESENTATIVE <br /> ©1988-2009 ACORD CORPORATION. All rights reserved. <br /> ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD <br />