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DocuSign Envelope ID:8DBFC7C8-DFF2-4179-9582-FA3E75937570
<br /> .,�C"RV CERTIFICATE OF LIABILITY INSURANCE 11/17 r,2014l
<br /> �- 11A�7,/20��
<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 CERTIIFiCATE 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 dares not confer rights to the
<br /> certificate holder in,lieu)of such ondorsoment(s).
<br /> PRODUCER CONTACT Maria t*fOniC{.7
<br /> NAME
<br /> JJ Wade & Associates PHCaNE , (704)8'92-9297 �� No I7rayes pass
<br /> P„O„ Boaz 1,209 E-MAIL mmonico @' 'wadelnsurance.com
<br /> aoohl�ss: �0
<br /> 2.12 S Main St. INSLIRERIS)AFFORDI NG COVERAGE NAIL#
<br /> _m.._.. _ .........
<br /> Davidson, No 28056 INSURERA Cincinnati Insurance Co
<br /> MpApy 10677
<br /> INSURED INSURERe:Accident Fund Ins Co o . ...... ....... ........_..
<br /> Medallion Athletic Products, Inc. INSURER G
<br /> 150 River Park Road INSURER D:
<br /> Mooresville, NC 28117 INSURER E:
<br /> INSURER F:.
<br /> COVERAGES CERTIFICATE NUMBER:14-15 Master COI REVISION NUMBERI
<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 DESCHiBIED HEREIN IS SUBJEC"T r0 ALL THE TERMS
<br /> EXCtU'SIONS AND CONDITIONS OF SUCH ROLI LIES.LIMITS SHOWN MAY HAVE BEEN REDU CED BY PAID CLAIMS.
<br /> <R °.__ TYPE.OF INSURANCE ...........A.DDL. .D.BR... POLICY NUMBER MMIDDIYY'NY MMMJQDIYY NY' .. ........ LIMITS
<br /> ILTR
<br /> GENERAL,LIABILITY EACH OCCURRENCE S 1,,000..,000
<br /> 5 CDMMERCIAI c I.I,NLI;AI.IS E'rLlTr rA1TaF I'e7R"rMNTF0 m
<br /> __. EBE. ,tLai cry urrenr ,. _ . ,_. ._, 300,000
<br /> 3/15/2014 3/15/2015 10 000
<br /> A ......... CLAIMS-MADE � CdCCI.YFv 'PP03BB45 MEOEMFyAa,y¢rr7eEre+r.5nmy S. a
<br /> X Contractual....Liability FER�0 NAlI nL� JURY a 1,000,000
<br /> GENERAL AGGREGATE $ 2,000,000
<br /> GENIA(,GREGArELIMITAPPL.IESPER�, PROCUCT5-a�r��rPK)PaGL; S 2,000,000
<br /> _, .....__._.... _ ...............
<br /> PRO.POLI4;Y X J.C. LCC
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE Cull
<br /> b�8 accaudent ..m 1 1 0I7Pl_qQ0
<br /> A ANY AUTO SOD]i Y IN JURY IL er person) 1
<br /> .._ ALL OWNED .... SCHEDULED BA0238846 3/15/2014. 3/15/2015 IECIENLY INJURY(Per acadert),1
<br /> AU r08 AUTOS ._... ..................
<br /> NCNB'OED PROPERTY DAMAGE
<br /> ..�HIRED Au ros AUTOS Per accutlemk) $
<br /> MediraV Payments $
<br /> X UMBRELLA ILAS X OCCU R FAIN gCCURRENL E 1' 5,000,000
<br /> A EXCESSLIABm mm mm CLAIMS-MADE kP023$$af /15/2014 3/15/2.015 AGGREGATE S 5,000,000
<br /> _._
<br /> DED RET,NrIONS 5
<br /> WORKERS COMPENSATION "ACSTATU� OOH
<br /> AND EMPLOYERS"LIA.BIILITY .__._ T.4 MSTIIIWeUL I EN' ..
<br /> ANY EXC�IOEIYLCUrYE EL EACH ACCIDENT $ 1 000 000
<br /> O FFICER IMEMBERLD NIA /15/2014 /152015 8 cv6039190 EL.D DISEASE EAEMPI.IY. E 1,000,000
<br /> If vra desrxVlrca uar,tyer -.......... ...,...._
<br /> DES('RIPT(>N OF OPERATIONS below E.L.D15EA,�,vE-F�E,7l,ll;Y LIMIT $ 1 000 000
<br /> A Leased/Rented Eq:uiPment EPP0238846 /15/2014 3/15/2015 LIrw $150,000
<br /> DESCRIPTION OF OPERATION'S I LOCATIONS I VEHICLES (Arlach ACORD 101,Additional Remarks Schedule,:if more space is required)
<br /> ,Jab: 101 Meadowlands Drive, Hillsborough, NC 27278
<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 /> ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Orange County
<br /> PO Box 8181
<br /> Recreation Factory Partners, LLC AUTHORIZED RE,PRESENTATIVE
<br /> 101 Meadowlands Drive
<br /> Hillsborough, NC 27278
<br /> Phillip A].e:cander/AFt
<br /> ACORD 2,5(2010/05) (01988.2010 ACORD CORPORATION. All rights reserved.
<br /> III oritd'w;inn "11ho Ar"trYd7f"h nom.nmd Innn area rcnict—rl marhrc of Ar^f ipn
<br />
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