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DocuSign Envelope ID:4109B2DB-ED41-4F53-BO69-OD7CB196EEA9
<br /> ACC->R,0 CERTIFICATE OF LIABILITY INSURANCE ATE IMWDDfYYYY)
<br /> 01413012015
<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 CSRTIFICATIE 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 cortifirate holder Is an ADDITIONAL INSURED,the policy(ies);must be endorsed, If SUBROGATION IS WAIVED,Subject to
<br /> the terms and conditions of tho 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 ondorsomont(s).
<br /> PRODUCER rONTAcT A,n-y .Paschal
<br /> NAME,.
<br /> "OH6ki PA X -846-2438
<br /> Ken B.Lawson,Jr. �Ax,No�Elfl: 919-846-2090 Iwc,Na�: 919
<br /> Elba Lawson Insurance Group,Inc. f.,MAII In :nationwide.com
<br /> ADDRiSS� P2SC "@
<br /> 66,12-1101 Six Forks Road INSURER(S)ArFO�RDING COVERAGE NAI�C 9
<br /> Raleigh,NC 27615 INSURER A: Nationwide Mutual Insurance Company 2378T
<br /> INSURED INSURERS: AmGU4R6insurance Company 21873,
<br /> Pro�Net Systems,Inc. NSURER C� Nationwide Mutual Fire ins Company 23779
<br /> 320D Glen Royal Road INSURER D:
<br /> Suite 107 INSURERE:
<br /> Raleigh,NC 276�17 INSURER V
<br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br /> THIS IS TO CERTIFY'THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE MSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHIER 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 /> INSR TYPE OF INSURANCE POLICYEFP Pcxtcyexp
<br /> I'TR j IMM1DRV(yyXI�fmwonlyyyy)
<br /> A X COMMERCIAL GENERAL LAARILITY Y Y ACP2272994383 �02/22/20116 02/2212016 EACH0rMJRREN(.E $ 1,000,000
<br /> -,0 W�Nl IED
<br /> X OCCUR
<br /> PREN16r5 S 100A00
<br /> X Contractual Liability
<br /> 5,000
<br /> X Contractoes Enhancement PERSONM&ADV",AAfflY S 1,0001,000
<br /> AG,(r,R::f,"GATr JM APPLIES PER G�ENE'�Alr A015REGATF s 2,000,000
<br /> POLICY X I I PRO-mic rs.EXWRX)PAGG $ 2,000,000
<br /> WHER
<br /> C AUTOMOBILE LMUILITY Y Y ACP3006921314 121311201512/31120161 CkMS�N;E[)SfN��LE U4117
<br /> '0--TIA � !2 $ 1,000,000
<br /> ANYAU�0 BL)Dj�Y NJORY(P�w
<br /> X ALLOW4��`) SCHEDULED
<br /> AUIOS 'A U�OS j BODLY INJURY�Pv accman,[�,S
<br /> X 1�'P�OPFRI�DAVA(�f,
<br /> X AW(Os annj�lt)
<br /> A X UMFIRIELLA UAB Y Y —460"2"2,"7,--9 9-4 3"3-3- W12212016,02/22120161 EACH CrOURRPNOL 4,000,000
<br /> X EXCESS LIA8 Ap�iRCGAT'E 4,000,000
<br /> ON) A RFTCNT0N$ none 5
<br /> R OTH-
<br /> B WORKERSCOMPENSA'TION Y PRW'C663376 '0410312015 0410312016 X n F FR
<br /> �AND EMP'LOYERS'LIABILNTY YIN
<br /> FA FACHAC,=FW
<br /> $ 1,0010,000
<br /> NIA
<br /> IMondawry in NHI Fk �,A5�-'ASE r.AEI/PWYLE S 1,000,000
<br /> L L LISE�ASE-POLK,Y_M11 r S 11,000,0100
<br /> DESCRIPTION OF OPERATIONS I LOCKTIONS VEHICLES(ACORD 1:01,Additional)Remarks Schedule,may be aftachad 11 more spaice Is Metered)
<br /> Orange County is Included as,additional insured and Waiver of Subrogation applies per Blanket Contractors Enhancement
<br /> Endorsement CG 72 88 under the general liability policy, The Umbrella/Excess Liability policy Is"follow form"(please refer to
<br /> attachment). Blanket Waiver of Subrogiation also applies to the workers compensation policy(please refer to attachment).
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County SHOULDANYOF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION: DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> P.0.Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS,
<br /> Hillsborough,INIC 27278
<br /> AUTHORIZED REPRLSFN�
<br /> E-Malk tcomar@orangecountync.gov
<br /> I E-MaW
<br /> plone stem c.co
<br /> 1�88-2014WC6ROCORPORATION, All rights reserved,
<br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
<br />
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