|
DocuSign Envelope ID: 5154D3BE-6CAD-4624-9E7E-46781 E534267
<br /> CERTIFICATE OF LIABILITY INSURANCE DATE JMMIDONYYY)
<br /> 04130/2015
<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 poficy(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 endorsement(s).
<br /> PRODUCER
<br /> Amy H.Paschal
<br /> ...............
<br /> Ken S.Lawson,Jr. PHONE, VAX,
<br /> JAIC"No Extj� 919-846-2090, (AJC me,: 919-846-2438
<br /> d1ba Lawson Insurance Group,Inc, E-MAIL
<br /> ADDRESS: pasch4iaC@nationwide.com
<br /> 6612-101 Six Forks Road INSURER(S)AFFORDING COVERAGE NAIC If
<br /> Raleigh,NC 27616 INSURER A: Nationwide Mutual Insurance Company 23787
<br /> INSURED INSURER B: AmGUARO Insurance Company 21873
<br /> ProNlet Systems,Inc, INSURER C Nationwide Mutual Fire ins Company 23779
<br /> 3200 Glen Royal Road INSURER 0:
<br /> Suite 107 INSURER r:
<br /> Raleigh,NC 27617 INSURER F.
<br /> I
<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 WTH 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' -"'AUDC'SUBA'
<br /> POLICY EFF POLICY EXP
<br /> LTIR TYPE OF INSURANCE POLICY NUMBER (NIMIDDINVI"I (MMf0WYYyY) LIMITS
<br /> A X COMMERCIALGENERALLIA81LITY y y 'ACP2272994383 0212212015 02122/2016 EACH OCCURRENCE 111 1,000,000
<br /> DKMA6,'F rrYOERTEM
<br /> CLAWS MADE 'X ,OCCUR 1010,000
<br /> X Contractual Liability 6"00,0
<br /> iX ontractoes Enhancement
<br /> PERSONAL&ADVINJURY 3 1,0�0!0,000:
<br /> LIMITAPP'LIES PER GENERAL ACGREGATE S 2,000,000
<br /> POUC-1 X L C)C PRODUC I'S,-COMPX)�AGG, $ 2,,066"
<br /> WHER
<br /> . .................................. N P11GLE LIII
<br /> C AUTOMOBILE LIAMLVEY Y Y ACP3006921314 121311201512/31120161 co"'""1" 1,000,000
<br /> X ANY AU 10 1300R,Y INJURY(Per pnelol� 3,
<br /> X ALL CANNED SCHMAED
<br /> AUITOS AUTOS BODILY IN (PeT J=juwll�
<br /> —1 W fY00N.'R'T Y DAMAO E
<br /> X 11REDAUTOS X ANU01 r-)0SVVT4'z U =K*rjly
<br /> A X UMBRELLA LIAR 'X ecLIR Y Y ACP227994333 0212212015,021221201161 4,0100,000
<br /> EXCESS LIAO
<br /> CLAIMS MADE AGGREGAIE S 4,000,000
<br /> DFD A RETEN11ON5 none R OTH- $
<br /> B WORKERS COMPENSAIION Y PRWC663376 04/0312D15041/0312016 X Ela
<br /> ANDEMPLOYERS�LIABILITY T
<br /> ANY YIN EL EACHACCIQENT $ 1,000,000
<br /> I C)�FkC-EiVMEVHER EXI'.LUDE D7 Fy] N/A
<br /> IMarldpOary On NVU
<br /> F,I, CA5EA9E EA EMPLOYEE S 1,000,000
<br /> DE 50UPT loW OF OPERA T 0145 below LL. DISLASE•POLICY LIMIT s 11,000,00
<br /> . ................
<br /> -DESCRIP VON O OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddItTartsO Remarks SchedLda,May be anathikd Of mom specs Is romt4rod)
<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 Subrogation,also applies to the workers compensation policy(please refer to attachment).
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Orange County SHOULD ANY OF THE ABOVE 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,INC 27'278
<br /> AUTHORIZED REPRESEN TAT
<br /> E-Mail. tcomar@orangecountync,gov
<br /> I E-Mai�Atf@plqnetsy.steTsne.com
<br /> 1 68-2014'ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
<br />
|