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DocuSign Envelope ID: F7F335BA-8B6B-4DF4-825C-8C793AOA9C6F <br /> OP ICI:KR <br /> '� Dk CERTIFICATE OF LIABILITY INSURANCE <br /> DATE 0711 �°°'16 <br /> 07/10/2015 <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 1S 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 endorsement(s). <br /> PRODUCER ]CUSTOMER ONTACT <br /> CITIZENS INSURANCE AGENCY AME: Kim Rhodes <br /> P O BOX 109 AJP L* E .252.492-4061 FAX No): <br /> HENDERSON,NC 27536 �IEBa.klm@ncagent tom <br /> House AccountlJoel T.Cheatham RODUCER <br /> ID N:CLUBN-2 <br /> INSURERS AFFORDING COVERAGE NAICN <br /> INSURED Club Nova Community,Inc. INSURERA:Scottsdale Insurance Company <br /> P.O.Box 1346 INSuRER B I PHILADELPHIA INSURANCE CO <br /> Carrboro, NC 27510-1345 INSURER C:LIBERTY MUTUAL INS GROUP <br /> INSURER R: <br /> INSURER E <br /> INSURER F r <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <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 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 /> ILTR TYPEOFINSURANOE POLICY EFF POtJO EXP <br /> POLICY NUMBER S1MlADlYYYY MMIDDIYYYY LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE 3 11000,00 <br /> A X COMMERCIAL GENERAL LIABILITY OPS0066706 05/13/2015 0710112016 PpE IEES Ea cw{re 3 300,00 <br /> X CLAIMS-MADE 11 OCCUR MER EXP(Any one parson) 3 5,000 <br /> X Retro 5113106 PERSONAL aADVINJURY s 1,000,000 <br /> GENERAL AGGREGATE S 3,000,000 <br /> i <br /> GENE AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AGG 3 3,000,000 <br /> X I POLICY PRO- LOC 3 <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 3 1,000,000 <br /> B X ANY AUTO ?HPK1336662 0511312015 0710112016 (EsaWdent) <br /> BODILY INJURY(Pot person) S <br /> ALL OWNED AUTOS BODILY INJURY(Per&Wdenl) 3 <br /> SCHEDULED AUTOS <br /> PROPERTY DAMAGE 3 <br /> B X HIREDAUTOS PHPK1336662 0511312015 0710112016 (PERACC€RENT) <br /> B X NON.DWNEDAUTOS PHPKI335662 0511312015 0710112016 MedPay $ 5,00 <br /> UMIUIM s 500,00 <br /> UMBRELLA L1 11 HOCCUR EACHOCCURRENCE 3 <br /> "CESS LIA13 CLAIMS-MARE AGGREGATE S <br /> r <br /> DEOUCTITILE 3 y <br /> RETENTION S 3 <br /> WORKERS COMPENSATION X WC 5TATU- QTH. <br /> AND EMPLOYERS'LtABIUTY YIN ELI <br /> C ANY PROPRIETORIPARTNERIEXECUTIVE LCC-641-438860-015 0511312015 0511312098 s L,FACH ACCIDENT S 500,000 <br /> OFFICERIMEMBER EXCLUDED? D NIA <br /> (Ma <br /> ndalory In NH) E L.DISEASE•EA EMPLOYEE $ 600,00 <br /> II qes describe under <br /> REST IPTiON OF OPERATIONS below E.L.DISEASE-POLtCY LIMIT S $00,00 <br /> A Professional Liab. 1OPS0066706 0511312015 07/0112018 EachClaim 1,000,000 <br /> Claims Made RETRO 5113106 Aggregate 31000,000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atleelt ACORD 161,Additional Ramrrks Schedule,R morn apace Is required) <br /> Auto Lciat bolder is additional insured under the General Liability and <br /> ty. I <br /> I <br /> CERTIFICATE HOLDER CANCELLATION i <br /> -- --- THE !EXPIRATION DATE THEREOF, D PO NOTICE WILL IAI:CANCELLED IN <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES<3E CANCELLED BEFORE <br /> Orange County Risk ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Manager <br /> PO Box 8181 AUTHORIZ E SENTATIVE ; <br /> Hillsborough,NC 27278 House cco Jo T.Cheatham <br /> I <br /> 0 88104 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD <br /> l <br />