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DocuSign Envelope ID:AEE43C90-CC92-4D5D-A539-7CAD6lB8867F
<br /> BIRSI.2 OP ID: LB
<br /> CERTIFICATE OF LIABILITY INSURANCE DATE(IAMIDD/YYYY)
<br /> o51a4/2o15
<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(loos not confer rights to the
<br /> certificate holder in lieu of such endorsement(s),
<br /> PRODUCER NOIITA _-CT _
<br /> Senn Dunn-GSO nnE Lynne A Meyer,CIC,CPIW,AINS _
<br /> 3625 N.Elm St. PHONE,EXa;336.346-"302
<br /> ) 12-3818 Greensboro,NC 27455 E A ,No:
<br /> David R.Clem,CIC A_DDRESS_Imeyer @senndunn,com
<br /> INSURER(S)AFFORDING COVERAGE NAIC Q
<br /> _ INSURER A_Transportation Insurance Co 20494
<br /> INSURED SIRS,Inc. INSURER B:Builders Mutual In$.CO, _ 10844
<br /> Mr.Raven Brooker INSURER c;Columbia Casualty Company 31127
<br /> PO Box 36197 _ Y p Y
<br /> Greensboro,NC 27416-6197 INSURER D;
<br /> INSURER E
<br /> INSURER F;
<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 /> 1LTf2 TYPE OF INSURANCE INSD ID r) POLICY NUMBER H?%DD 'I�%ODD LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
<br /> CLAIMSdAADE l�OCCUR C1071978219 05101/2015 0510112016 PREMISES Ea occurrence $ 100,00
<br /> MED EXP(Any one person) 3 5,00
<br /> X
<br /> PERSONAL&ADV INJURY $ 1,000,00
<br /> GEN'L AGGREGATE LIMIT APPLIES PER, GENERAL AGGREGATE $ 2,000,00
<br /> POLICY JEo 0 LOG PRODUCTS•COIAP;OPAGG $ 2,000,00
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
<br /> Ea accident $ 1,000,00
<br /> A X
<br /> ANY AUTO C1071978222 05101/2015 05/01/2016 BODILY INJURY(Parperson) $
<br /> ALLOWNED SCHEDULED -
<br /> AUTO$ AUTOS BODILY INJURY(Per accident) $
<br /> X HIREDAUTOS x NON-OWNED PROPERTYDAMAGE
<br /> AUTOS Per accident)
<br /> X UMBRELLA LIAB X ComplColl Ded $ 1,00011,00
<br /> OCCUR EACH OCCURRENCE $ 5,000,00
<br /> A EXCESS LIAB CLAIMS-MADE 01071978253 0510112015 05/01/2016 AGGREGATE $ 5,000,00
<br /> DED X RETENTIONS 10,000 $
<br /> WORKERS COMPENSATION
<br /> AND EMPLOYERS'LIABILITY YIN X _STATUTE ERH
<br /> B ANYPROI.II!B6REXCLUDEO?ECUTIVE NlA 'PWGI00029002 05/01/2015 05101/2016 E.L_EACH ACCIDENT $ 500,00 Fn
<br /> Ityestory bNnd E. .DISEASE-EAEIAPLOYE S 500,00
<br /> II yes,descrbeunder —-
<br /> DESCRIPTIONOFOPERA710NSbe!ow E.L.DISEASE-POLiCYDh11T $ 500,00
<br /> A Rental Equipment 01071978219 05/0112015 05/0112016 Limit 100,00
<br /> C E&OlPollution CE05001855996 05/01/2015 05!01/2016 Limit
<br /> 1,000,00
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached If more space is required)
<br /> i
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> ORANWS
<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 />
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