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"� NORTH06 OP ID:76
<br /> CERTIFICATE OF LIABILITY INSURANCE
<br /> DATE 08/13/2014 Y)
<br /> 08/13/20!4
<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 P ODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the cortifibate holder is an ADDITIONAL INSURED,the policy(les) 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 /> Debnam and Company LLC PHONE -
<br /> Po Bx 98 �, ,5) 919/269 9177 i N,} 919/269738
<br /> Zebulon,NC 27597 MaL
<br /> Debnam&Co.(P&C)
<br /> ADDRESS!..._._._ __ _. .._-..-.._.._.. ...._......._.......... .. ._. ._.....
<br /> _............................ NAIC#
<br /> INSURER A:Firemen's Insurance of Wash.DC 21784
<br /> _ .._............_-...._......................................__..__......._......__......... ..................................
<br /> INSURED North State Resurfacing,Inc. INSURER 8:Stonewood Insurance Co. 11828
<br /> PO OX 387 INSURER C
<br /> Wendell, NC 27591 _ _ .......... ____....,._........__ ... ....._...._.__......._._..... .......
<br /> INSURER D:
<br /> INSURER E:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 1 REVISION NUMBER: 0
<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 /> ................................._..... ...._.._.
<br /> LTR I TYPE OF INSURANCE POLICY NUMBER M/DD/YYYY 14A ) LIMITS
<br /> GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
<br /> . ...................................................................
<br /> A j X COMMERCIAL GENERAL LIABILITY X PA101724344 i 0110512014 01/05/2015 AGE YO RINMO 500 00
<br /> _ PREMISE${Ee_occwrertimi,____$ , ......
<br /> CLAIMS-MADE X OCCUR j MED EXP(Any one person) $ _10,00
<br /> ..,.,_ _..______.._.._........ .................. ..._._....._......._.
<br /> s }
<br /> PERSONAL&ADV INJURY $ 1,000,00
<br /> 2,000,00
<br /> I GE N'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $ 2,000 00
<br /> ! k
<br /> 3 POLICY X RO-P .^ LOC .._....$
<br /> AUTOMOBILE LIABILITY ,j aMBINEDll;SINGLE LIMIT $ 1,000,00
<br /> A ' X E ANY AUTO CPA701794344 11 01105/2014 01/0512015 BODILY INJURY(Per person) $ _
<br /> ALLOWNED SCHEDULED I BODILY INJURY(Per accident) $
<br /> AUTOS AUTOS
<br /> ' NON-OWNED P'RQPERTYpAN}itGE-._._-------__}
<br /> HIRED AUTOS AUTOS (PER ACCIQANT)„,- $,
<br /> X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00
<br /> A EXCESS LIAB__ CLAIMS-MADE CPA101794344 01/0512014 0110512015 AGGREGATE $ 1,000,00
<br /> X._.. -- I ...._.-,._____._ ._ _.._._. .... ,.__. _...
<br /> DED RETENTION$ $
<br /> WORKERS COMPENSATION X WC STATU- OTH-
<br /> 1 AND EMPLOYERS'LIABILITY YIN QBY�.IJI( ._._.. ..E3_._... ..........._.._.
<br /> B ANY PROPRIETOR/PARTNER/EXECUTIVE C10000091832014A 01/0112014 01/01/2015 EL EACH ACCIDENT $ 1,000,00
<br /> I OFFICERIMEMBER EXCLUDED? N/A —----„ - -----._ ..
<br /> I(Mandatory inNH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00
<br /> I If Yea,describe under 1 _w____..—..__.._....._.. ..__. ._...._..........__.._.--..._..__
<br /> I DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1,000,00
<br /> I
<br /> I 3
<br /> I
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If mom space Is required)
<br /> Orange County, its officers, official agents and employees are included as
<br /> additional insureds regarding general liability per CLCG 0024 0113 attached.
<br /> I
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> 9 ty ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Attn: Risk Management
<br /> PO Box 8181 AUTHORIZED REPRESENTATIVE
<br /> 200 South Cameron Street
<br /> Hillsborough,NC 27278
<br /> ©1988-2010 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
<br />
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