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DocuSign Envelope ID: C9DOF1 D8-58FA-4F8F-ABEB-899CF01A1 F8B 5THWA-1 OP ID; AJ <br /> ,a <br /> CERTIFICATE OF LIABILITY INSUIRANC�E D0212 12015 <br /> 02123x'201 <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(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 does not confer rights to the <br /> certificate holder in lien of such endorsement(s). <br /> PRODUCER CONTACT cT Anna Jane Coltrain <br /> Hartsfield Nash A envy,Inc. PHONE. ..... _._ FAX <br /> Post Office Box 1109 IAC,,NQ.EXt 919-556 3696 _ I c,gip) <br /> Ware 1Forest,N1C 27688 E-MAIL <br /> Lorie Borrelli,CIC,AAI _ - <br /> ......_IINSURIERI'S)AFFORDING COVERAGE .......,.,. NAIC# <br /> INSURER A Hartford Casualty Ins Co 29424 <br /> ... .. <br /> INSURED 5th Wall Building Diagnostics In tern Insurance Co. 119!43? <br /> Consultants, LL INSURERC:Le '__ <br /> 9601 Bailywlrick Rd l __ _.... <br /> _____ ...... ..... <br /> !Raleigh, NC 276115 INSURER <br /> INSURER E <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS 1S 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 /> inlsix t1 <br /> ......... -- AD-sUB I POLICY EFaErr p�ri=lcv Exw __ ._ ...... . .......... ......... <br /> LTR TYPE OF INSURANCE POLICY NUMBER I MMIDDIYYYY l (MMIDDNYYYI LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 2,000,00 <br /> ALAI"T1=rI�„ <br /> A X COMMERCIAL.GENERALLIABILITY 22aBAVF4089 12101/2014 12401/2015 PREMISESIEaocc rrence °� 300 00C <br /> ... ...............� CLAIM'S-MADE [X OCCUR MED EXP CAny one person) S 10,00( <br /> PERSONAL.&AOVINJURY $ 2000,00 <br /> — GENERAL AGGREGATE $ 4,000,00 <br /> GENT AGGREGATE LIMIT APPLIES PER, PRODUCTS-COMP/OP AGG �5 4,000,00 <br /> PTTLICY IRS- LOC $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE.LIMIT ..... <br /> -_ ,(La acpdent) ...... 2,000,00 <br /> ..._...... ... .. . ... ---- 010 <br /> ANY AUT°G 22SBAVF'0089 12101/2014 12/01112015 BODILY INJURY(Per person) $ <br /> ALL OWNED � SP'HErSLyIwE.O BODILY INJURY(Per accident) S <br /> AUTOS ....... AUTOS <br /> NON-OWWNED .PROPERTY DAMAGE.._ ...... <br /> X HIRED AUTOS X, AUTOS ��ER AC�II7ImmNr <br /> $ <br /> I <br /> ... <br /> UMBRELLA LIAB OCCUR EAa H OCCURR2ENCE $ 1,000,00 <br /> A EXCESS LIAR J CI AIMS MADE 22SBAVF0089 12101/2014 121011/20151 AGGREGATE $ <br /> DEO X RETENTION$ $ <br /> WORKERS COMPENSATION ( " W"fC";aTATU. OIH <br /> AND EMPLOYERS'LIABILITY T �' -SIT'$ 1'� .. . <br /> YIN <br /> AN'wE"ROPRIETURIPARTNER�EXEhL'UTIVE'. Pq' �Ip J �FL EACHI,ACCIDENT $ <br /> CFFICERfMFMBER EXCLU10C 4 4._..._..7 N r A .... . .. ..... .... . .. _ .. .. <br /> (Mandatory in,NH) E.I..DISEASE.L-A ECwkG'.rLC)YLE'.... $tinder If o scRIp"nON OF OPFRAM"IONS below 1 E L DISEASE-PdDLiCY LIMf7` $ <br /> B Professional 43926702 0211212014 02!12/201510ccur 11,000,00 <br /> Liability JAggregate 11000,00 <br /> DESCRIPTION'.OF OPERATIONS x LOCATIONS A VEHICLES (Attach ACORD 101.„Additional Remarks,Schedule„It more space Is required) <br /> RE.Cates Farmhouse i Blackwood Farmhouse <br /> CERTIFICATE HOLDER CANCELLATION <br /> ORAN818 <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 27276 AUTHORIZED REPRESENTATIVE <br /> ✓1966-2010 ACORD CORPORATION. All rights reserved!. <br /> ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD <br />