|
DocuSign Envelope ID:4E43C797-33A3-4C29-9D23-96EA82AC437C
<br /> BIRSI.2 OP ID; LE
<br /> CERTIFICATE OF LIABILITY INSURANCE DATE(h1h11D0/YVYY)
<br /> 05/04/2015
<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 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 lieu of such endorsemenl(s),
<br /> PRODUCER NAME:
<br /> Senn Dunn•GSO _Lynne.A Meyer,CIC,CPIW,AINS
<br /> -
<br /> 3625 N.Ehn SL PHONE Ext1:336-346-1302 AX No):338.612-3818__
<br /> Greensboro,NC 27455 E-MAIL
<br /> David R.Clem,CIC ADDRESS: me er Y @ se nndunn.com
<br /> INSURER(S)AFFORDING COVERAGE NAIC A.
<br /> INSURER A:Transportation Insurance Co, 20494
<br /> INSURED SIRS,Inc, INSURER B:Builders-Mutual ins,Co, _ 10844
<br /> Mr,Raven Broeker INSURER C;Columbia Casualty Company 31127
<br /> PO Box 36197 Y p Y
<br /> Greensboro,NC 27416-6197 IN$URERD:
<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 gPOLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> ILTR TYPE OF INSURANCE II SD y D POLICY NUMBER dINDDY� INJIDDlYYYY I LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
<br /> cLAlrts►JADE _X1 uOCCUR 01071978219 05101/2015 05101/2016 PREMISES Eaoccurrence $ 1.00,00_
<br /> MEDEXP.(Any one person) $ _5,0_0
<br /> X PERSONAL&ADV INJURY $ 1,000,00
<br /> GEN'L AGGREGATE LIIJIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
<br /> POLICY a JEC LOC
<br /> PRODUCTS•COMPjOPAGG $ 2,000,00
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY CO BI ED SINGLE LIMIT
<br /> Ea accident $ 1,000,00
<br /> A X ANyAUTO 01071078222 05/01/2015 0510112016 BODILY INJURY(Per person) $
<br /> AUTOS SCHEDULED BODILY INJURY Per accident) $
<br /> AUTOS AUTOS t
<br /> HIRED AUTOS NON-OWNED
<br /> X }( PROPERTYDAMAGE
<br /> AUTOS Per aalde 1 $
<br /> Comp/Coll Ded $ 1,000/1,00
<br /> X UMBRELLALIAB X_I OCCUR EACHO_CC_URRENCE $ 5,000,00
<br /> A EXCESS LIAB – CLAIMS•MADE C1071978253 05/01/2015 05/09/2016 gGGREGATE $ 5,000,00
<br /> DED X I RETENTION$--- 10,000 $
<br /> WORKERS COI,iPENSATION X STATUTE ORH-
<br /> AND EMPLOYERS'LIABILITY _
<br /> B ANY PROPRIETOR/PARTNERIEXECUTIVE YIN `PWC100029002 05/01/2015 05/01/2016 E.L.EACH ACCIDENT $ 500,00
<br /> OFFICERAIEMBEREXCLUDED? NIA —
<br /> (Mandatory inNH) E.L.DISEASE-EA EMPLOYE. $ 500,00
<br /> if yes,describe under ----
<br /> DESCRIPTION OF OPERATIONS be:o;r E,LDISEASE-POLICYLIhd1T $ 500,00
<br /> A Rental Equipment 01071978219 05/01/2015 05/0112016 Limit 100,00
<br /> C E&O/Pollution CEOSOOI855996 05101/2015 0510112016 Limit 1,000,00
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additlonal Remarks Schedule,may be attached If more space Is required)
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORANINS
<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 AUTHORIZED REPRESENTATIVE
<br /> ©1988-2014 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
<br />
|