2015-545-E AMS - FloorChem, Inc. to install epoxy flooring at the Sheriff's Office

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DocuSign Envelope ID: FFF24A59-BA65-479A-B4C4-5483423483E9 HC�VKLJ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD 10/29/2014 014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Sue Alford John Hackney Agency of Rocky Mount PHONE (252)442-3186 FAX No, A/C No:(252)451-9400 950 Country Club Road AADDAResS:Salford@ jharm.com P. 0. BOX 7807 INSURERS AFFORDING COVERAGE NAIC# Rocky Mount NC 27804-0807 INSURERA:Selective Insurance Co of SC 19259 INSURED INSURER B:Hartford Ins. Co. of Midwest 37478 Floorchem,Inc. INSURER C: 200 Powell Dr. , Ste 103 INSURER D: INSURER E: Raleigh NC 27606 INSURER F: COVERAGES CERTIFICATE NUMBER:CL14102901483 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL S BR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES a occurrenc E e $ 100,000 A CLAIMS-MADE FxIOCCUR S2002943 11/1/2014 11/1/2015 MED EXP(Any one person) $ 10,000 PERSONAL BADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 X POLICY X PRO- AUTOMOBILE $ AUTOMOBILE LIABILITY EO MBIINEDtSINGLE LIMIT 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED 2002943 11/1/2014 11/1/2015 BODILY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ Underinsured motorist $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A [JEXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 D I X I RETENTION$ c S2002943 11/1/2014 11/1/2015 $ B WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory inNH) 2WBCEG1705 11/1/2014 11/1/2015 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Project:Orange County Jail-Flooring Upgrades @ 125 Court Street, Hillsborough, NC CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Sue Alford/PSA ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025rgninamni Thn A( r)Pn name and Innn nre reniafnmrl m�r4e of Arr)Pn