2014-466-E AMS - Tile Restoration, Inc. for WHSC initial sealing process $4,580

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EpdvTjho!Fowf Ipgf!,E;!B63G1C35.9141.51 EG9:37.4G1 4323BDl 35 A`�°O® CERTIFICATE OF LIABILITY INSURANCE 8/14/2014' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Leanne Turner NAME: Jake A Parrott Insurance Agency Inc PHONE (252)523-1041 FAX (252)523-0195 A/C No 2508 N HERRITAGE STREET ADDRESS:lturner @parrottins.com PO BOX 3547 INSURERS AFFORDING COVERAGE NAIC# KINSTON NC 28502 INSURERAMAIN STREET AMERICA ASSURANCE 29939 INSURED INSURERBNGM INSURANCE COMPANY 14788 TILE RESTORATION INC INSURER C: C/O ALBRITTON CO INSURER D: PO BOX 160 INSURER E: HOOKERTON NC 28538-0160 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1311506507 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLI CIES.LIMITS SHOWN MAY HAVE BEEN REDU CED BY PAID CLAIMS. 1�7R TYPE OF INSURANCE ADSL WVDR POLICY NUMBER MMIDIDY� MM/DDY� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 500 000 PREMISES Ea occurrence $ � A CLAIMS-MADE Fx_]OCCUR APK8262X 11/7/2013 11/7/2014 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 X DEDUCTIBLE: $0 GENERAL AGGREGATE $ 2,000,000 GENI AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED 2K8262X 11/7/2013 11/7/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident L I Medical payments $ 2,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED I X I RETENTION$ 0 CUK8262X 11/7/2013 11/7/2014 $. B WORKERS COMPENSATION X WCYSTATU- LIM TS I OTH- AND EMPLOYERS'LIABILITY YIN ANY OFFICER/MEIMBOER EXCLUDED?ECUTIVE Y N/A E.L.EACH ACCIDENT $ 1,0001000 (Mandatory in NH) K8262X 11/4/2013 11/4/2014 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate holder is an additional insured under form #BPM3105 (ATTACHED) . Coverage for the additional insured will be primary/non-contributory if required in the written contract or agreement between the parties. Insurer waives the `Transfer of Rights of Recovery Against Others to Us' clause if required in the written contract between the parties PER FORM BP 0497 (ATTACHED) . The endorsement s amending the business owners liability coverage form includes several additional insureds automatically. The endorsement states that additional insured status is only provided if there is a written contract or agreement between the parties requiring such status. AUTO: Insurer agrees to waive the `Transfer of CERTIFICATE HOLDER CANCELLATION tcomar@orangecountync.gov SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ORANGE COUNTY ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 8181 600 HWY 86 NORTH AUTHORIZED REPRESENTATIVE HILLSBOROUGH, NC 27278 Leanne Turner/LEANNE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 ownnm m Tha Ar-r1Rfl Tama nnrl Innn mra ranictararl marlrc of ARr1RrT