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DocuSign Envelope ID: B4DACCFE-C86E-4740-BCC9-75E2B72C18BO <br /> Erie CERTIFICATE OF INSURANCE DATE ISSUED(MM/°Dm) <br /> e® 1/21,15 <br /> Insuranc <br /> —THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY— <br /> Home Office • 100 Erie Ins-trance Place • Erie,Pennsylvania 16530 • 814870.2000 <br /> Toll free 1 800.458.0811 - Fax 814.870.3126 - www.erielnsirance.com <br /> NAME AND ADDRESS OF AGENCY THE BALLARD AGENCY INC AGENT'S NO. <br /> JJ1010 C RIE IN NCE C PANY <br /> 105 W KING ST Co.-D ERIE INSUBANEE PROPERTY_&—CASUALTY COMPANY <br /> HILLSBOROUGH,NC 27278-2543 Co.:E ERIE INSURANCE EXCHANGE, lNot Applicable <br /> re Indemnity Co.,Attorney In Fact\ in NY <br /> Co.:-F ERIE INS_U_RANCE COMPANY OF NEW YORK _ <br /> Co.v IS FLAGSHIP CITY INSURANCE OMPANY <br /> (919)732-2158 IThis certificate is issued for information purposes only and confers <br /> NAME AND ADDRESS OF NAMED INSURED no rights on the certificate holder.It does not affirmatively or <br /> negatively amend,extend,or otherwise alter the terms,exclusions <br /> THE HISTORICAL FOUNDATION OF and conditions of insurance coverage contained in the policy(ies) <br /> HILLSBOROUGH&ORANGE CO INC indicated below.The terms and conditions of the policy(ies)govern <br /> the insurance coverage as applied to any given situation.Limits <br /> 201 N.CHURTON ST. shown may have been reduced by claims paid.This certificate of <br /> insurance does not constitute a contract between the issuing <br /> HILLSBOROUGH,NC 27278-2535 insurer(s), authorized representative or producer and the <br /> certificate holder. <br /> This is to cerb that licies,as Indicated by the Policy Number below,are in force for the Named Insured at the time that the Certificate is being_issued. <br /> T <br /> 0 ns'd <br /> , TYPEAF INSURANCE POLICY NUMBER " I LIMITS <br /> E 7 GENERAL LIABILITY 8/22/15 8/22/16 EACH OCCURRENCE I$ 1 000 000 <br /> rX COMMERCIAL GENERAL LIABILITY Q442250193 FIRE DAMAGE(Any One Fire)' 1,000,000 <br /> ❑CLAIMS MADE ❑X OCCUR, MED EXP(Any One Perunj $ 5,000 <br /> PERSONAL&ADV.INJURY! 1,000,000 <br /> GENERALAGGREGATE '', 2,000,000 <br /> GENT AGGREGATE LIMITAPPLIESPERr. PRODUCTS-COMP/OPAGGi 2,000,000 <br /> IDX POLICY ❑PROJECT ❑LOC <br /> AUTOMOBILE LIABILITY BODILY INJURY <br /> "ANYAUTO"(OWNED WNED)' (EACH PERSON) $ <br /> ❑OWNED BNJURY <br /> EACHACCIDEACHACN $ <br /> ! <br /> P HIRED PROPERTY DAMAGE $ <br /> I-- <br /> ❑ NON-OWNED BODILYINJURYAND <br /> ❑GARAGE PROPERTYDAMAGE <br /> COMBINED Is <br /> EXCESS LIABILITY EACH OCCURRENCE $ <br /> ❑ OCCURRENCE AGGREGATE $ <br /> RETENTION $ $ <br /> E WORKERS COMPENSATION& <br /> EMPLOYERS LIABILITY Q92 2200215 8.22/15 8/22/16 BODILY' ACCIDENT $ 100,000 EACH ACCIDENT <br /> NJURY DISEASE $ 500,000 POLICY LIMIT <br /> BY DISEASE $ 100,000 EACH EMPLOYEE <br /> OTHER <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS <br /> CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIV- <br /> ERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the <br /> terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer <br /> rights to the certificate holder in lieu of such endorsement(s). <br /> NAME AND ADDRESS OF CERTIFICATE HOLDER <br /> ORANGE COUNTY GOVERNMENT AUTHORIZED REPRESENTATIVE <br /> PO BOX 8181 <br /> HILLSBOROUGH,NC 27278 <br /> - ----r-vim___ -- <br /> EIG6230 8/11 11 of 1 <br />