|
DocuSign Envelope ID: D0190336-4C5C-477F-8902-D25F81947OB6
<br /> ,,.,. ► DATE(MWDDNYYl
<br /> �CERTIFICATIE OF LIABILITY INSURAN'ICE F10/30/201Y4
<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(les) must be endorsed. If SIUBROGATION 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 Molder in lieu of such endorsement(s).
<br /> PRODUCER CONTACT Beverly Pike, A.AawI
<br /> Jake A Parrott Insurance Agency Inc PriOwaE . (252)5231041 PA� N� czs2)S 3-C1145
<br /> 2508 N HERRI TAGE STREET e«q l .bpi ke @parret,tins.com
<br /> PO BOX 3547 _ MSURER(S)AFFORDING COVERAGE NAIL#
<br /> KINSTON NC 28502 INSURER EMPLOYERS MUTUAL CASUALTY CO 21415
<br /> INSURED INSURER B.FIASCO INSURANCE COMPANY 21407
<br /> TILE, RESTORATION INC INSURER
<br /> C,/O ALBRITTON CO INSURER D: _I......
<br /> PO BOX 160 INSURER.E:
<br /> HOOKERTON NC 28588-09160 INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER°-.CL14102908345 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 PERTACN,, 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 /> IN'SR ........ ......... ............ATyDE.'UiBR...._... ......... ........... POLICY EFF ��POLICY EXP LIMITS
<br /> LTR TYPE OF INSURANCE POLICY NUMBER. MWDQ1YYYN MMIDDPYYYY
<br /> GENERAL.IUABIUTY EACH OCCUR'RE.NrE: 5 1,000,000
<br /> DA
<br /> A COMMERCIAL GENERAL
<br /> 5D2054E MEEntwFlu
<br /> a uo=rrencpp S 500,000
<br /> Tf7/2014 11/7/2e1B yon Y 10 QOp pr�
<br /> d..........
<br /> Ptrf;;2NAI.YLADV INJURY F 1,000,000
<br /> GENERA At�ORFGATE t 2,000,000
<br /> {ENLAG GREGArE LIMIT APPLIESP''i:R�. PRGDUJ'•CT,:+...COMPa�JF�AGG 5.. 2,000,000
<br /> — POLICY X U}U 0- _.. LOC � _._..._ �. ._...
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
<br /> 1 CLO
<br /> A X
<br /> .. ANY AUTO BODIL Y IN UR:Y CPe perscn) $
<br /> AUTO,ALL C ED SCHEDULED 5E20546 11/7/2014 11/7/2015 BODILYNJURY(PeracadenG) S
<br /> IiiTPEPTY DAMAGE .........AUTOS
<br /> NON14)MJE:
<br /> HIRED AUTOS AU-TbS, Pe accEtientl.L___ $
<br /> _..
<br /> Medical pavirnents $ 2,000
<br /> X UMBRELLA LIAB OCCUR BAC H OCCURRENCE $ 2,000,000
<br /> EXCESS LIAR CLAWS—MADE AGGREGATE S 2,000',000
<br /> LOet) RETENItON S J20546 11./7/2014 11/7/2015 s..
<br /> B WORKERS COMPENSA71ON ?C I VV C STATU} OT H-
<br /> AND EMPLOYERS'LIABILITY YIN 'Y"L .V1'`r' .....
<br /> ANY PROS RIETORIPARTt,9ERiF.�,NG:CUTIVIE E L.EACH Af,C ICU@ NT S TL�R��7�1 000
<br /> OI'PICERNEMREP E:xy",La.,uti.;c� Y II NIA H2O,.546 i.id4/2D1,4 llf4/201 _.. ..._ _ ......,_
<br /> )Mandatory In NN) E L..DISEASE-FA EMPLOYEE.00 6X000,
<br /> D blROnP7(wrdJwJFmCPERAPIeaIV Iaatw __ E.L.LISrA d°i eluu:'GLIMaT 4 1.p_ d9Q.r0049
<br /> DESCRIPTION OF OPERATION'S I LOCATIONS I VEHIICLES (Attach ACO'RD 141,Additional Remarks Schedule,PP more space is recpudred)
<br /> CERTIFICATE HOLDER IS LISTED AS AN ADDITIONAL INSURED AS PERTAINS TO GENERAL LIABILITY, ON A PRIMARY
<br /> BASIS INCLUDING PRODUCTS & COMPLETED OPERATIONS, VIA. A WRITTEN CONTRACT IN PLACE WITH THIS REQUIREMENT
<br /> INCLUDED. CERTIFICATE HOLDER IS LISTED AS AN ADDITIONAL IN'SURE'D AS PERTAINS TO AUTO! LIABILITY, VIA A
<br /> WRITTEN CONTRACT IN PLACE WITH THIS REQUIREMENT INCLUDED. WAIVER OF SUBROGATION IN FAVOR OF ADDITIONAL
<br /> INSURED APPLIES TO GENERAL AND AUTO LIABILITY AND WORKER'S COMPENSATION, VIA A WRITTEN CONTRACT IN PLACE
<br /> WITH THIS REQUIREMENT INCLUDED.
<br /> EXCLUDED OFFICERS IN WORKER'S COMPENSATION COVERAGE; DAVID ALBRITTON F CHARLES ALBRITTON III.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION (DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> ORANGE COUNTY ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> PO BOX 8181
<br /> HILLSBOROUGH, NC 27278 AUT44ORIZEDREPRESENTAnVE
<br /> Allen Parrott✓LEANN'E
<br /> ACO�RD 25(2010105) Od 1988-20110 ACOORD CORPORATION. All rights reserved.
<br /> INSO25 rwrrurwi,� ni 'ITha.&r".r11f11 e"r mo mnrd tnnn nrua ranietrarnri rmm2rirc of Arr1Rr1
<br />
|