2014-548-E AMS - Tile Restoration, Inc. for floor restoration in Whitted Building B Dental Clinic Restrooms $3,535

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DocuSign Envelope ID: 098EB4F2 -C3F4- 4867- B5FC- 1 14E7E9097CF ACOOR " CERTIFICATE OF LIABILITY INSURANCE 8/14/2014 D/YYYY) 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 Jake A Parrott Insurance Agency Inc 2508 N HERRITAGE STREET PO BOX 3547 KINSTON NC 28502 CONTACT Leanne Turner NAME: PHONE (252) 523 -1041 A/C No: (252) 523 -0195 Ext, ADDRESS: lturner @parrottins. COm INSURERS AFFORDING COVERAGE NAIC # INSURERAMAIN STREET AMERICA ASSURANCE 29939 INSURED TILE RESTORATION INC C/O ALBRITTON CO PO BOX 160 HOOKERTON NC 28538 -0160 INSURERB:NGM INSURANCE COMPANY 14788 INSURER C: INSURER D: INSURER E : $ 1,000,000 INSURERF: X COMMERCIAL GENERAL LIABILITY 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 REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL S SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD /YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence 500 000 $ r A CLAIMS -MADE OCCUR MPK8262X 11/7/2013 11/7/2014 MED EXP (Any one person) $ 10,000 PERSONAL 8 ACV 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 Ee eBccliAeDtSINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ B X ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED 1 HIRED AUTOS AUTOS 2K8262X 11/7/2013 11/7/2019 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccident $ Medical payments $ 2,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 B EXCESS LIAB CLAIMS -MADE DED X RETENTION$ 0 $ UK8262X 11/7/2013 11/7/2014 B WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N NIA CK8262X 11/4/2013 11/4/2019 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 11000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIP71ON OF OPERATIONS I 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 ULK I II-IL;A I t MULULK L ANt,CLLH I IUIV 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) NS025 rqm nnei m ©1988 -2010 ACORD CORPORATION. All rights reserved. The ar.np l name 1 Inn^ am ronicfcrnrl mnrlec ^f Ar npn